Monday, September 6, 2010

Window on Eurasia: Russia’s Doctor Shortage Forces Rural Hospitals to Close, Pushing Up Death Rates

Paul Goble

Staunton, September 6 – Increases in mortality this summer in the Russian Federation were not only the result of forest fires and pollution from them but also the closure of dozens of rural hospitals, a step that has deprived “hundreds of thousands” of Russians of “the chance to obtain contemporary and qualified medical assistance.”
In many cases, Albert Khasimov of “Novaya versiya” reports, these institutions have been closed because there are no longer any doctors or other medical specialists to operate them, a reflection of a severe shortage of such doctors and the unwillingness of the remaining ones to work outside major cities (
According to the health ministry, Russia has a doctor shortage of some 230,000, but that number, as Khasimov observers is “like an average temperature in a hospital.” In cities and especially major ones, the shortage is much smaller than in rural areas, something that is true not only among regions but within them.
In Pskov oblast, which has long been notorious for the high death rates among rural men, there are 74.7 times as many doctors per capita in the oblast center than there are in the rest of that district, the worst figure of its kind anywhere in the Russian Federation. And in many regions there, as in the others, there are simply no rural doctors at all.
And this problem affects not only non-Russian republics and oblasts and krays far from Moscow but also regions at the center of the Russian Federation. In Kursk oblast, for example, there are no surgeons in one district, but most of those in the others are 55 or older. As a result, officials say, in the very near future, “a third of the districts of the oblast” may lack surgeons.
Meanwhile, in Smolensk oblast, a quarter of the surgeon slots, 38 percent of the anesthesiologist slots, and 32 percent of the traumatologist positions are unfilled. And “the situation will soon become still worse because in three of the districts there remain only pension-age surgeons.”
And in Kostroma oblast, the 11,000 residents of the Soligalich district lack a single neuro-pathologist, something that prompted officials there a month ago to appeal through the local newspaper to residents: “If anyone knows a doctor who might like to work in Soligalich, please advise the administration.”
Other oblasts are attempting to attract doctors by offering them cash if they agree to come, but this has not solved the deficit of doctors. And doctor salaries in rural areas remain low. The so-called “Lunacharsky system,” named for an early Soviet official, remains in place. Under its terms, “grateful patients” are supposed to make up for low salaries.
The doctor shortage in rural Russia, of course, is not just about money, Khasimov says. Doctors as highly educated professionals want the cultural facilities that the major cities provide and that rural areas don’t. And those trained in Moscow often refuse to leave, even if they could do better financially elsewhere.
That has resulted in a situation in which Moscow and St. Petersburg have more doctors per capita, 68.9 per 10,000 in the former and 74.9 per 10,000, than do Americans (28 per 10,000), Germans (34 per 10,000) or Israelis (38 per 10,000), while Russia as a whole has far too few.
(There are some exceptions, Khasimov notes. The most prominent of these is Chukotka where there are more doctors per capita than in either of the capitals, the results of the efforts of local medical schools to retain graduates and of the relatively small size of the population of that Far Eastern republic.)
Russia has a large system of medical training institutions, almost 50 medical schools and 28 medical faculties at regional universities. They graduate approximately 50,000 doctors a year, but with the collapse of the Soviet system of assigning doctors to the first posts, few choose to go to rural areas.
One promising effort at correcting this situation, Khasimov says, involves agreements among schools, regions, and banks under the terms of which students have their training paid for by the banks and then the regions pay off this debt if the graduate works five years in them. Those who don’t have to pay the banks back on their own.
The regions most interested pursuing in this approach, Khasimov says, are those with fewer than 30 doctors per 10,000 population: Chechnya (24.1), Kurgan (24.5), Ingushetia (24.9), Kaliningrad (29.8), the Jewish Autonomous Oblast (29.9) and Tula (29.9). But others are moving in this direction as well.
And there are also some indications that the latest cohort of Russian doctors, like its predecessors in pre-1917 Russia, is more animated by the desire to be of service than those trained in the 1990s. At that time, Oleg Yanushevich, a medical school rector in Moscow, said “the dollar decided everything.” Now, he pointed out, other values are more important.

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