Medical University Of SofiaDemographics of Russia

Firat GULLUFaculty No: 5139

Group:39

This publication tries to debunk some popular, but misguided, views on demographic trends in today's Russia. These consist of the perception that Russia is in a demographic "death spiral" that dooms it to national decline (Biden, Eberstadt, NIC, CIA, Stratfor, etc). Some extreme pessimists even predict that ethnic Russians - ravaged by AIDS, infertility and alcoholism - will die out as an ethnicity, displaced by Islamist hordes and Chinese settlers (Steyn, Collard).

The Myth of Russia's Demographic Apocalypse

Think again. While it is true that Russia's current demographic situation is nothing to write home about, most of the demographic trends that matter are highly positive - and there is compelling evidence that Russia can still return to a healthy, longterm pattern of sustainable population replacement.

1. MYTH: Russia is losing 750,000 of its population per year and will become depopulated within decades.

REALITY: In 1992, for the first time since the Great Patriotic War, deaths exceeded births in Russia, forming the so-called "Russian Cross". Since then the population fell from 149mn to 142mn souls.However, the rate of depopulation has slowed massively in recent years.

As of 2008, there were 362,000 more deaths than births in Russia, down from 847,000 in 2005. Furthermore, adding in migration would give a total population loss of just 105,000 people in 2008, equivalent to -0.07% of the population, which is a massive improvement from the 721,000 fall in 2005. The situation continued improving in 2009, despite the economic crisis, with Russia seeing positive natural increase in August and September for the first time in 15 years.

[Source: Rosstat; analyzed & published by Sergey Slobodyan @ Sublime Oblivion].

Though this is still far from demographic salubrity, the situation today more resembles the stagnation seen in Central Europe than the catastrophic collapse of the transition era, and the trends remain positive. As such, pessimistic predictions of imminent demographic apocalypse are becoming increasingly untenable.

2. MYTH: Granted, Russia's crude birth rates have risen in recent years. But this was all due to the big size of the 1980's female cohort, which reached childbearing age in the 2000's; since the 1990's cohort is about 40% smaller, birth rates will tumble again.

[Source: Rosstat; edited by Anatoly Karlin].

REALITY: From 1999-2007, only 37% of the increase in the crude birth rate was due to an increase in the size of the childbearing age segment of the population (only 10% in 2007 itself). The rest came from an increase in the total fertility rate (TFR), the average number of children a woman can be expected to have over a lifetime, irrespective of the structure of the age pyramid.

Speaking of which, Russia's TFR has risen from a nadir of 1.16 children per women in 1999, to 1.49 children in 2008 (and thus also breaking the "lowest-low" fertility hypothesis that states that no society has ever recovered from a fertility collapse to below 1.30 children). The figures for 2009 will almost certainly show a TFR above 1.50.

This is not to say that the coming reduction in the fertility contribution of the 1980's "youth bulge" will not exert a growing downwards pressure on Russian birth rates in the next two decades. However, a growing TFR will be able to partially, or even fully, counteract these adverse trends.

3. MYTH: The recent rise in fertility is small and fragile, based on the temporary effects of new maternity benefits and pro-natality propaganda. It will shatter as soon as the first economic crisis interrupts Russia's petro-fueled swagger.

REALITY: It is true that Russia's current TFR, at 1.5 children per woman, is well below the 2.1 needed for long-term population stability. That said, there are compelling reasons to believe that we seeing an incipient fertility reversal in Russia.

First, fertility expectations today are little different from those of the late Soviet era when the TFR was near replacement level. According to numerous surveys since the early 1990's, Russians consistently say they want to have an average of 2.5 children. This is broadly similar to respondents from the British Isles, France and Scandinavia, who have relatively healthy TFR's of around 1.7-2.1. This suggests Russia's post-Soviet fertility collapse was caused by "transition shock" rather than a "values realignment" to middle-European norms, where people only want 1.7-1.8 children.

Second, a major problem with the TFR is that it ignores the effects of birth timing. A more accurate measure of long-term fertility is the average birth sequence (ABS), which gives the mean order of all newborn children. If in one fine year all women in a previously childless country decide to give birth for some reason, the TFR will soar to an absurdly high level but the ABS will equal exactly one.

[Source: Demoscope; edited by Anatoly Karlin].

In Russia the ABS remained steady at 1.6 children per woman from 1992-2006, little changed from the 1.8 of Soviet times, even though the TFR plummeted well below this number. This indicates thatmany women were postponing children until they settled into careers and improved their material wellbeing -- a hypothesis attested to by the rising age of mothers at childbirth since 1993. As such, it is not unreasonable to expect a compensatory fertility boom in the 2010's.

[Source: Demoscope; edited by Anatoly Karlin].

Though this may be a false positive if many women remain childless, the 2002 Census indicated that only 6-7% of women did not have any children by the end of their reproductive years. This indicates that childlessness is not in vogue and worries about widespread abortion-induced sterility are overblown.

Third, a new, confident conservatism has recently taken hold in Russian society. After two decades of disillusionment, at the end of 2006 consistently more Russians began to believe the nation was moving in a positive than in a negative direction. The state began to reconstruct an ideological basisfor belief in Russia's future, which included the aforementioned maternal benefits and pro-natality campaigns - and contrary to pessimist assertions, the examples of France and Sweden indicate that such efforts tend to be successful at incubating longterm improvements in TFR. Can it really be the case that the genesis of Russia's rediscovery of belief in itself, and of consistent improvements in its demography, were a matter of mere coincidence?

Fourth, the cohort now entering the workforce will probably enjoy greater job opportunities and higher wages because of the imminent shrinking of Russia's labor force. This may provide incentives to marry earlier and have more children, which would compensate for this cohort's smaller size. Nor are they likely to be subjected to taxes high enough to discourage family formation; relative to continental Europe, Russia is still a younger nation and can be expected to enjoy high energy revenues in the post-peak oil age.

Finally, the economic crisis has come and gone - and in stark contrast to popular predictions of arenewed fertility collapse and higher deaths from alcoholism (which I challenged in the face ofheavy opposition), Russia saw its first two months of natural population growth for the last 15 years in August and September 2009. So the notion that Russia's demographic recovery is built on quicksand has been objectively refuted.

4. MYTH: Russia's main demographic problem is not the fertility rate, but a dismally low life expectancy, especially for middle-aged men.

REALITY: It is true that Russia's life expectancy is exceptionally bad by industrialized-world standards. Death rates for middle-aged men today are, amazingly, no different from those of late Tsarism -- a phenomenon Nicholas Eberstadt termed "hypermortality". This tragic development is almost entirely attributable to the extreme prevalence of binge drinking of hard spirits, which accounts for 32% of Russia's aggregate mortality (compared to 1-4% in West European nations)

However, not all demographic indicators are created equal. High mortality rates only have a direct impact on the replacement-level TFR when significant numbers of women die before or during childbearing age, as in Third World countries. Russia's infant mortality rate of 8.5 / 1000 in 2008 is close to developed-country levels and not statistically significant. Though tragic and unnecessary, its "hypermortality" crisis mainly affects older men and as such has negligible direct effects on fertility.

That said, mortality rates must be curbed if Russia is to avoid significant population decline in the coming decades. Contrary to prevailing opinion, plans to raise life expectancy to 75 years by 2020 or 2025 are feasible if approached seriously. From 1970-1995 in Finnish Karelia, better healthcare and lifestyle reforms reduced incidences of heart disease, Russia's main cause of death, by over 70%. Considering the sheer size of the gap between Russia and the advanced industrial world, even modest improvements will have a big impact.

These modest improvements are now coming about. Russia is now installing new equipment in oncology centers, aims to increase access to hi-tech medical services from 25% to 80% by 2012, and is becoming more serious about implementing anti-smoking, anti-alcohol and safety measures. In 2008, Russia's life expectancy, as well as deaths from accidents (including alcohol poisoning, violence, and suicide), have improved past the (pre-transition) levels of 1992 - and the recovery continues into 2009.

5. MYTH: There is an unrivaled panoply of social ills in Russia, such as sky-high rates of abortion, alcoholism and accidents. These will induce Russians to disinvest in the future, which will result in low economic growth and a perpetuation of its death spiral into oblivion.

REALITY: Quite apart from this being a "mystical" explanation for national decline, and hence unscientific, this assertion is not backed up by the historical record. All these social ills first manifested themselves in the USSR from around 1965 (accompanied by sky-rocketing male mortality rates), yet nonetheless, that did not preclude Russia from maintaining a near replacement level TFR until the Soviet Union's dissolution - and ultimately, that is all that matters for maintaining longterm population stability.

The Russian abortion rate was nearly twice as high during the Soviet period relative to today, but today's prevalent fears of widespread infertility as a byproduct somehow never materialized - the 2002 Census indicated that only 6-7% of women did not have any children by the end of their reproductive years. Today, abortions continue on their longterm decline, even in the aftermath of the late-2008 economic crisis (and despite the hysterical predictions to the contrary).

[Source: Demoscope; edited by Anatoly Karlin].

Similarly, excessive alcohol consumption - the major cause of "hypermortality" amongst middle-aged Russian men - set in long before the post-Soviet demographic collapse.

(Observe how closely Russia's historical mortality trends correlate to Nemtsov's estimates of alcohol consumption in the graph below). Yet as mentioned above, high middle-aged

male mortality rates have no direct impact on fertility rates. Furthermore, since there is no major discrepancy between the numbers of men and women until the age of 40, women

have no physical problem in finding mates (though it is true that high mortality and alcoholism amongst males has a suppressing effect on new couple formation, the late Soviet experience

suggests that it does not altogether preclude a healthy TFR).

[Source: Rosstat, V. Treml & A. Nemtsov; note that the official Goskomstat (Rosstat) figures ought to be discarded because they do not account for moonshine, which may

constitute as much as half of Russia's alcohol consumption].

The demographer Eberstadt asserts that Russia's high mortality rates preclude human capital formation through education because men facing elevated mortality risks (supposedly) discount its future value; consequently, this dims the prospects for longterm economic growth. This hypothesisdoesn't stand up to the evidence. The late Soviet Union had one of the world's highest tertiary enrollment rates, and more than 70% of today's Russians get a higher education. This should not be surprising due to human psychological factors - "deaths from heart disease and accidents only happen to other people"; and besides, even if a Russian man assumes he'll die in his 50's or 60's, he'd still rather live comfortably, avoid the military draft, etc, than sweep the streets. So this argument is flawed on many, many levels.

It is true that poor health lowers economic productivity. However, one should note the caveats that 1) hypermortality disproportionately effects poorer, lower-educated people, 2) in the post-agrarian society, the main driver of productivity improvements is education - not health, and 3) there is a silver lining in that by curbing aging, a low life expectancy also relieves pressure on pensions. Finally, drunkenness by itself cannot check the growth of a vital civilization -- after all, America was known as the Alcoholic Republic during the early 19th century.

6. MYTH: The ruling elite's criminal neglect of Russia's growing AIDS crisis will soon result in hundreds of thousands of annual deaths, further accelerating its demographic collapse.

REALITY: Institutions like the World Bank were predicting hundreds of thousands of deaths by 2010, yet the death toll for 2008 was only 12,800. Further, the percentage of pregnant women testing HIV positive plateaued in 2002, suggesting the epidemic remains essentially contained among injecting drug users.

[Source: 2008 Russian AIDS Progress Report].

The problem with the "doomer" models used to predict apocalypse (Eberstadt, NIC, Ruhl et al, etc) is that their projections of imminent mass deaths from AIDS unrealistically assume heterosexual, sub-Saharan Africa transmission patterns, which is unbacked by sociological analysis or surveillance data. A more rigorous model by the Knowledge for Action in HIV/AIDS in Russia research program predicts a peak HIV prevalence rate of under 1% of the total Russian population by around 2020. Thus far, it correlates with reality.

Finally, following a period of real neglect of the problem until 2005, the Russian state has sinceramped up spending on AIDS to an annual 0.5bn $. One can no longer speak of official negligence.

7. MYTH: Faster-breeding Muslims will constitute the majority of the Russian Federation's citizens by 2050, placing the dwindling Orthodox Russians under a brutal dhimmitude.

REALITY: Ethnic Russians still make up nearly 80% of the population, whereas only 4-6% of the population consider themselves to be Muslim in opinion polls. The fertility rates of the biggest Muslim ethnicities, Tatars and Bashkirs, is little different from the national average.

Even the Caucasian Muslim republics experienced a drastic fertility transition in the last twenty years, as a result of which the only one to still have an above-replacement level TFR is Chechnya. However, Chechnya's 1.2mn people constitute less than 1% of the Russian total.

So the fact of the matter is that Russian Muslims simply do not have the demographic base to become anywhere near the Federation's majority ethnicity in the foreseeable future.

[Source: Rosstat; edited by Anatoly Karlin].

Furthermore, the main reason some people fear - or relish - the prospect of an Islamic Russia is because they associate Russian Muslims with their less progressive co-religionists in the Middle East. In reality, vodka has long since dissolved away the Koran in Russia. The vast majority of Muslim Russians are loyal citizens, having made their peace with the imperial Russian state long ago;imminent dhimmitude is a myth, the product of fevered imaginations.

8. MYTH: The Chinese are taking over the depopulating Russian Far East by a stealth demographic invasion; tempted by Siberian Lebensraum and vast mineral riches, they will eventually seize it outright from a weakening Russia.

REALITY: There are no more than 0.4-0.5mn Chinese in Russia (and probably a good deal less). The vast majority of them are temporary workers and seasonal traders who have no long-term plans of settling in Russia. Even though the Russia Far East depopulated much faster than the rest of Russia after the Soviet collapse, at more than 6mn today, Russian citizens remain ethnically dominant.

Furthermore, the average Manchurian has no objective desire to migrate to Siberia and squat illegally in a pre-industrial farm in a God-forsaken corner of the taiga. Alarmism on this issue is a trifecta of ignorance, Russophobia, and Sinophobia (the "Yellow Peril").

Though the possibility that Malthusian pressures will eventually force China into aggressive expansionism cannot be discounted, it would be suicidal to intrude on Russia because of its vastnuclear arsenal.

9. MYTH: But all the demographic models indicate that Russia is going to depopulate rapidly!

REALITY: Not all of them. I give an alternate range of scenarios that see Russia's population change from today's 142mn, to 139mn-154mn by 2025, and 119mn-168mn (medium -- 157mn) souls by 2050.

In the "Medium" scenario, life expectancy reaches 74 years by 2025 (today's Poland) and 81 years in 2050 (today's Canada); the TFR rises from 1.4 children per woman in 2006 to 2.0 by 2015, before gently descending to 1.7 from 2025 to 2050; and there is an annual influx of 300,000 net migrants. (These assumptions are plausible, based on a realistic knowledge of the current situation (see above), and a modest amount of confidence in Russia's spiritual regeneration and capability to sustain economic modernization). The resulting population dynamics are reproduced below.

[Source: Anatoly Karlin @ Sublime Oblivion].

But even assuming Russia's TFR gets stuck at 1.5 children per woman in 2010 - i.e. slightly lower than its level today, while retaining the aforementioned mortality and migration trajectories, the population size will remain basically stagnant, going from 142mn to 143mn by 2023 before slowly slipping down to 138mn by 2050.

On the basis of this model, I made several falsifiable predictions back in July 2008, whose fulfillment will confirm its validity (or not). The three most important predictions are the following:

Russia's population will start growing again by 2010. Natural population increase will resume by 2013. Total life expectancy will exceed 70 years by 2012.

My results are somewhat similar to Rosstat forecasts which see the population growing to 134mn-145mn (medium -- 140mn) by 2025. Furthermore, both of them are, at least thus far, more in line with reality than the older "doomer" models, which by and large failed to predict the recent demographic improvements.

10. MYTH: Okay then, the vast majority of models by respectable institutions - i.e., not those of Kremlin mouthpieces like Rosstat or yourself - project that Russia's population is going to plummet to 100mn or so people by 2050.

REALITY: First, appeal to authority & association fallacy. Second, you can check the reliability of my model because my source code is open and accessible for all, which is more than you can say for many of these "respectable institutions". Third, the problem with the aforementioned "doomer" models is that they are all essentially based on linearly extrapolating Russia's post-Soviet fertility and mortality situation into the far future, assuming negligible improvements or even a deterioration (as in the models including the imminent, but fortunately non-existent, African-style AIDS epidemic).

It is my belief that Russia's demographic "doomers" ignore the importance of the post-Soviet resilience of Russia's fertility expectations, the evidence that Russia's post-Soviet demographic collapse was just an aberration caused by its wrenching transition to a new socio-political system, and the newly-emerging sociological trends that are returning Russia's to its past-and-future Empire - trends that are restoring Russians' faith in the future, reinforcing social conservatism, and creating the conditions, with the Kremlin's active support, for a major demographic reversal out of the post-Soviet abyss.

I would be the first to admit that this interpretation of Russian society may be incorrect, and consequently so are my "optimistic" demographic projections. Feel free to disagree with my interpretation, but do note that 1) I accurately called the economic crisis as a non-event in relation to Russia's demography and 2) made falsifiable, near-term predictions about Russia's future demography, which few other crystal-ball gazers care to do.

Speaking of crystal balls, I would like to end this by noting that pretty much all demographic projections beyond 20 years into the future - the approximate time needed for a new cohort to reach reproductive age - are near-useless in practical terms. Any simplistic extrapolation will eventually founder on the discontinuities inevitably produced by complex human systems: for a past example, compare 20th century French and German demographic history; regarding the future, note the profoundly disruptive potential of two strong concurrent trends - limits to growth, and technological singularity - either of which could so radically transform human life in the 21st century, as to render modern demographic analysis meaningless as a scientific tool.

Anatoly Karlin is an independent blogger who writes about Russia, geopolitics, and global trends at his blog Sublime Oblivion. He is currently working on a book about the "future history" of the 21st century.

In 2010, 1,140,368, or 56% of all deaths in Russia were caused by cardiovascular disease. The second leading cause of death was cancer which claimed 292,310 lives (14.3%).

External causes of death such as suicide (1.7%), road accidents (1.4%), murders (0.9%), accidental alcohol poisoning (0.7%), and accidental drowning (0.5%), claimed 206,336 lives in total (10.2%). Other major causes of death were diseases of the digestive system (4.5%),

respiratory disease (3.6%), infectious and parasitic diseases (1.6%), and tuberculosis (1.1%).[50] The infant mortality rate in 2010 was 7.5 deaths per 1,000 (down from 8.2 in 2009 and

16.9 in 1999).[51][52]

As of 2010, the average life expectancy in Russia was 63.03 years for males and 74.87 years for females.[53] The average Russian life expectancy of 68.98 years at birth is nearly

10 years shorter than the overall average figure for the European Union, or the United States.[54] The largest contributing factor to the relatively low life expectancy is high mortality among working-age males due to preventable causes such as accidents, alcohol poisoning,

violent crimes, heart disease etc.[citation needed] Some infectious diseases are also implicated, such as AIDS/HIV and tuberculosis, which became more widespread in Russia in the 1990s because of the deterioration in the healthcare system. In the late 1950s, the USSR

had a higher life expectancy than the United States,[55] but the Soviet Union has lagged behind Western countries in terms of mortality and life expectancy since the late 1960s. The

life expectancy was about 70 in 1986,[56] prior to the transition-induced disruption of the healthcare system. The turmoil in the early 1990s caused life expectancy in Russia to

steadily decrease while it was steadily increasing in the rest of the world. Recently however, Russian life expectancy has again begun to rise. Between 2005—2010 the male life

expectancy in Russia rose by over four years, increasing the overall life expectancy by nearly 4 years to 68.98.[53]

Abortions

In the 1980s only 8–10% of married Russian women of reproductive age used hormonal and intrauterine contraception methods, compared to 20–40% in developed countries. This led to much higher abortion rates in Russia compared to developed countries: in the 1980s Russia had a figure of 120 abortions per 1,000 women of reproductive age compared with only 20 per 1,000 in Western countries. However, after the dissolution of the Soviet Union many

changes took place, such as the demonopolization of the market for contraceptive drugs and media liberalization, which lead to a rapid conversion to more efficient pregnancy control

practices. Abortion rates fell in the first half of the 1990s for the first time in Russia's history, even despite declining fertility rates. From the early 1990s to 2006, the number of expected abortions per women during her lifetime fell by nearly 2.5 times, from 3.4 to 1.2. As of 2004, the share of women of reproductive age using hormonal or intrauterine birth control methods

was about 46% (29% intrauterine, 17% hormonal).[57]

Despite clear progress in family planning, the target of desired children at the desired time for a large portion of Russian families has not yet been achieved. According to a 2004 study, current pregnancies were termed "desired and timely" by 58% of respondents, while 23%

described them as "desired, but untimely", and 19% said they were "undesired". The share of unexpected pregnancies remains much lower in countries with developed family planning

culture, such as the Netherlands, whose percentage of unwanted pregnancies 20 years ago was half of that in Russia today.

Mortality

The social and economic crises that gripped Russia in the early 1990s are reflected in increased mortality and declining life expectancy, especially among able-bodied males. Contributing to Russia's long-term population decline is a projected mortality rate increase from 11.3 per 1,000 population in 1985 to 15.9 per 1,000 in 2005. Russia's mortality rate reached its lowest level, 10.4 per 1,000 population, in 1986 (for which a state anti-alcohol campaign received substantial credit); then the figure rose steadily in the ensuing decade. The largest jump was from 12.2 to 14.6 per 1,000 between 1992 and 1993; after having reached 15.7 per 1,000 in 1995, the rate was projected to remain virtually flat over the next decade.

According to 1994 statistics, the life expectancy for Russian males had reached 57.3 years and for females 71.1 years. These are the lowest figures and the largest disparity by sex for any country reporting to the World Health Organization, and they are a sharp decline from the 1987 levels of 64.9 years for males and 74.6 years for females. In 1990 the Russian Republic ranked only seventh in this statistic among the fifteen republics of the Soviet Union. The lag in the average life expectancy of males was attributed to alcohol and tobacco abuse; to unsafe conditions at work, on the road, and in the home; and to declining heath care.

Mortality rates are especially high for able-bodied males in rural areas. Served poorly by the health care system and lacking basic sanitary facilities and conveniences, many farming communities have been transformed into enclaves for the elderly, the indigent, and the sick. Moreover, indigenous nationalities such as the Evenks and the Nenets have suffered catastrophic declines in life expectancy and high rates of sickness and death that have prompted speculation that some of those groups may become extinct. Geographically, the lowest average life expectancy in Russia is in the Siberian Republic of Tyva, and the highest figures are in the Caucasus Republic of Dagestan and in the Volga region. In the first half of the 1990s, the imbalance between the birth and death rates was especially acute in major

cities. In Moscow and St. Petersburg, the number of deaths in 1992 was almost double the number of births.

Since 1987 mortality from accidents, injuries, and poisonings has risen significantly, from 101 to 228 per 100,000 population. Contributing to that figure are an estimated 8,000 fatal workplace accidents per year, largely the result of aging equipment, the proliferation of risky jobs in the unofficial "shadow economy," and the deterioration of work discipline. For the period between 1990 and 1994, the suicide rate rose by 57 percent to a total of nearly 62,000, putting Russia in third place among eighty-four developed countries. The stress of the transition period is one explanation for this rising statistic. The homicide rate rose by more than 50 percent in the same period. In 1994 Russia's 35,000 motor vehicle deaths nearly equaled the 40,000 in the United States, although Russia has less than 1 percent as many automobiles. Deteriorating roads and declining police discipline are the main causes of that fatality statistic.

The chief natural cause of death is diseases of the circulatory system, which accounted for 769 deaths per 100,000 population in 1993. The next causes in order of frequency are cancer and respiratory diseases. Among people of working age, 41 percent of deaths are attributable to unnatural causes; the proportion of such deaths was highest in Leningrad Oblast, the Permyak Autonomous Region, the Republic of Tyva, and the Evenk Autonomous Region. The number of alcohol-related deaths also climbed in the mid-1990s; the 1994 figure was 25 percent higher than the 1993 total. In some regions, alcoholism has assumed epidemic proportions; in the Bikin Rayon of Khabarovsk Territory on the Pacific coast, nearly half the deaths between 1991 and 1995 were alcohol related.

The overall aging of the population also is an important factor in the higher mortality rate. Between 1959 and 1989, the percentage of retirees in the population and the percentage of Russians eighty or older nearly doubled, although declining life expectancy already was reducing the impact of that trend in the mid-1990s.

Healthcare in Russia

Russia has more physicians, hospitals, and health care workers than almost any other country in the world on a per capita basis. However, since the collapse of the Soviet Union,

the health of the Russian population has declined considerably as a result of social, economic, and lifestyle changes. After Vladimir Putin became president in 2000, there was significant growth in spending for public healthcare[5] and in 2006 it exceed the pre-1991

level in real terms.[5] Also life expectancy increased from 1991-93 levels, infant mortality rate dropped from 18.1 in 1995 to 8.4 in 2008. Russian Prime Minister Vladimir Putin announced a large large-scale health-care reform in 2011 and pledged to allocate more than 300 billion rubles ($10 billion) in the next few years to improve health care in the country.He also said that obligatory medical insurance tax paid by companies for compulsory medical insurance

will increase from current 3.1% to 5.1% starting from 2011.

Common causes of death

In 2008, 1,185,993, or 57% of all deaths in Russia were caused by cardiovascular disease. The second leading cause of death was cancer which claimed 289,257 lives (14%). External causes of death such as suicide (1.8%), road accidents (1.7%), murders (1.1%), accidental

alcohol poisoning (1.1%), and accidental drowning (0.5%), claimed 244,463 lives in total (11%). Other major causes of death were diseases of the digestive system (4.3%),

respiratory disease (3.8%), infectious and parasitic diseases (1.6%), and tuberculosis (1.2%).

The infant mortality rate in 2008 was 8.5 deaths per 1,000, down from 9.6 in 2007. Since the Soviet collapse, there has been a dramatic rise in both cases of and deaths from

tuberculosis, with the disease being particularly widespread amongst prison inmates.

Smoking

Russia is the world leader in smoking. According to a survey reported in 2010 by Russia’s Health and Social Development Ministry, 43.9 million adults in Russia are smokers. Among

Russians aged 19 to 44 years, 7 in 10 men smoke and 4 in 10 women smoke.[16] It is estimated that 330,000-400,000 people die in Russia each year due to smoking-related

diseases.

Alcoholism in Russia

Alcohol consumption and Alcoholism are major problems in Russia. It is estimated that Russians drink 15 litres (26 pints) of pure alcohol each year. This number is nearly 3 times

as much as it was in 1990.[17] In Moscow on September 24 of 2009, Russia's interior minister Rashid Nurgaliyev cited the average intake at an estimated 18 liters a year; "In

Russia, each person, including babies, accounts for about 18 liters of spirits per year. In the opinion of WHO experts, consumption of more than 8 liters per year poses a real threat to

the health of the nation. Russia has long exceeded this level".[18] It has even been reported that excessive alcohol consumption is to blame for nearly half of all premature deaths in Russia.[19] A recent study blamed alcohol for more than half the deaths (52%) among

Russians aged 15 to 54 from 1990 to 2001. For the same demographic, this compares to 4% of deaths for the rest of the world.[20]

HIV/AIDS in Russia

HIV/AIDS, virtually non-existent in the Soviet era, rapidly spread following the collapse, mainly through the explosive growth of intravenous drug use.According to a 2008 report by

UNAIDS, the HIV epidemic in Russia continues to grow, but at a slower pace than in the late 1990s. At the end of December 2007 the number of registered HIV cases in Russia was

416,113, with 42,770 new registered cases that year. The actual number of people living with HIV in Russia is estimated to be about 940,000. In 2007, 83% of HIV infections in Russia

were registered among injecting drug users, 6% among sex workers, and 5% among prisoners. However, there is clear evidence of a significant rise in heterosexual transmission.

In 2007, 93.19% of adults and children with advanced HIV infection were receiving antiretroviral therapy.

The Russian Federation has demonstrated a high-level commitment in response to the AIDS epidemic. In April 2006, the State Council met with the Russian President to set goals for

developing a strategy for responding to AIDS; improving coordination, through the creation of a high-level multisectoral governmental commission on AIDS; and establishing a unified

monitoring and evaluation system. A new Federal AIDS Program for 2007 - 2011 was also developed and adopted. Federal funding for the national AIDS response in 2006 had

increased more than twentyfold compared to 2005, and the 2007 budget doubled that of 2006, adding to the already substantial funds provided by the main donor organizations.

Coordination of activities in responding to AIDS remains a challenge for Russia, despite increased efforts. In 2006, treatment for some patients was interrupted due to delays in

tender procedures and unexpected difficulties with customs. Additionally, lack of full commitment to an in-depth program for education on sex and drugs in schools hinders

effective prevention programs for children.[24]

Suicide

In 2008, suicide claimed 38,406 lives in Russia. With a rate of 27.1 suicides per 100,000 people, Russia has one of the highest suicide rates in the world, although it has been

steadily decreasing since it peaked at around 40 per 100,000 in the mid-late 90s,including a 30% drop from 2001 to 2006. In 2007 about 22% of all suicides were committed by people aged 40–49, and almost six times as many Russian males commit suicide than females. Heavy alcohol use is a significant factor in the suicide rate, with an estimated half of all

suicides a result of alcohol abuse. This is evident by the fact that Russia's suicide rate since the mid-90s has declined along-side per capita alcohol consumption, despite the economic

crises since then; alcohol consumption is more of a factor than economic conditions.

Pre-reform health care

Pre-1990s Soviet Russia had a totally socialist model of health care with a centralised, integrated, hierarchically organised with the government providing free health care to all

citizens. All health personnel were state employees. Control of communicable diseases had priority over non-communicable ones. On the whole, the Soviet system tended to primary

care, and placed much emphasis on specialist and hospital care.

The integrated model achieved considerable success in dealing with infectious diseases such as tuberculosis, typhoid fever and typhus. The effectiveness of the model declined with

underinvestment. Despite the fact that the quality of care began to decline by the early 1980s,medical care and health outcomes were on par with western standards. Despite a

doubling in the number of hospital beds and doctors per capita between 1950 and 1980, The lack of money that had been going into health was patently obvious. Some of the smaller

hospitals had no radiology services, and few has inadequate heating or water. A 1989 survey found that 3% of Russian hospitals did not have piped hot water and 1.2% did not even have

piped cold water.

Reform in 1991-1993

The new Russia has changed to a mixed model of health care with private financing and provision running alongside state financing and provision. Article 41 of the 1993 constitution

confirmed a citizen's right to healthcare and medical assistance free of charge. This is achieved through compulsory medical insurance (OMS) rather than just tax funding. This and

the introduction of new free market providers was intended to promote both efficiency and patient choice. A purchaser-provider split was also expected to help facilitate the

restructuring of care, as resources would migrate to where there was greatest demand, reduce the excess capacity in the hospital sector and stimulate the development of primary

care. Finally, it was intended that insurance contributions would supplement budget revenues and thus help to maintain adequate levels of healthcare funding.

The OECD reported[citation needed] that unfortunately, none of this has worked out as planned and the reforms have in many respects made the system worse. The population’s

health has deteriorated on virtually every measure. Though this is by no means all due to the

changes in health care structures, the reforms have proven to be woefully indequate at meeting the needs of the nation. Private health care delivery has not managed to make much inroads and public provision of health care still predominates. The resulting system is overly

complex and very inefficient. It has little in common with the model envisaged by the reformers. Although there are more than 300 private insurers and numerous public ones in

the market, real competition for patients is rare leaving most patients with little or no effective choice of insurer, and in many places, no choice of health care provider either. The

insurance companies have failed to develop as active, informed purchasers of health care services. Most are passive intermediaries, making money by simply channelling funds from

regional OMS funds to healthcare providers.