We’re well into the second decade of the 21st century, but Russia’s regional healthcare system remains ill. Some of its symptoms survive from the Soviet period, others came as a result of post-Soviet reforms.
A good example can be found south of the Urals. Bashkortostan, a republic of some four million, has a healthcare system exhibiting the entire spectrum of problems that plague Russian healthcare in general. Patients complain of huge lines at local clinics and the avalanche of new paid services in local hospitals. Doctors resent their low salaries and endless “optimisations” of medical institutions, which slash jobs in favour of outsourcing.
According to a poll conducted by the pro-Kremlin Union of Rural Youth and the United People’s Front, Bashkortostan is one of several regions dealing with the brunt of worsening medical care. If you speak to the region’s doctors, they’ve few illusions that things can improve.
The doctor is on strike
Svetlana Yusupova was on a hunger strike for 40 days. When she fell critically ill, she was denied hospitalisation in Ufa, Bashkortostan’s capital.
Yusupova, who is in charge of the Ordzhonikidze ambulance substation, began her hunger strike last March. In an open letter to Bashkortostan’s health minister, she accused the ambulance administration of creating disorder, deliberately creating shortages and worsening working conditions.
Svetlana Yusupova was on a hunger strike for 40 days
Yusupova was joined by 11 other employees at the Ordzhonikidze and Central substations, who demanded that the staff list of the ambulance brigades be updated to reflect standard work norms. They also insisted that administrative pressure against the members of the independent union Deistvye (literally: “Action”) cease, and that chief Ufa ambulance doctor, Marat Ziganshin, be fired, believing him to be the cause of the current problems.
Maria Yavgildina, nurse and participant of the ambulance workers’ hunger strike in Ufa. Photo courtesy of the author.
“Conditions at our substation are terrible,” said Deistvye member, striker and nurse Marina Yavgildina. “Our work has become simply impossible. Although we are paid the same, we are now called up one and a half times more than all of the other ambulance substations in Ufa. People are exhausted, they need to do twice as much as they did before and are dealing with administrative pressure on top of it all.”
The March 2016 hunger strike was not the first protest action by Ufa’s medical personnel. The first time Bashkortostan’s doctors openly protested was in July 2014, after the Deistvye union was first established in the region. This independent organisation was established by Andrei Konoval, a well-known trade unionist and civil activist from Udmurtia.
At that time, around one hundred Ufa ambulance workers who had joined Deistvye picketed the Ufa Sports Palace. The protesters demanded the return of extra pay for night shifts and overtime, decent quality uniforms and more modern ambulances to replace their deteriorating vehicles.
“Due to low salaries, harsh working conditions, and work overload, around 200 members of ambulance mobile teams have quit since the start of the year, and more continue to quit,” Konoval said at the protest. “Right now, not a single ambulance brigade in Ufa has the equipment it is required to have by law.”
The local government partially responded to protesters’ demands, beginning an inquiry into the work of the Ufa ambulance administrators. Yet reprisals against protesters and the attempt to fire Svetlana Yusupova resulted in a wave of hunger strikes which took place in the autumn of 2014 and spring of 2015. ”Accessible healthcare for all!” Ambulance workers hold a picket in Ufa, Bashkortostan, 2014. Photo courtesy of the author.The conflict at the ambulance station became a regular subject of investigations at the Bashkortostan legislature. Words of unequivocal support for the strikes were voiced in the medical community and among independent Russian and international union organisations. Public interest led to decreasing pressure on the doctors, but working conditions at Ufa’s ambulance stations still did not improve.
Grounds for a conflict between workers and the administration remained. The battle entered a new stage in 2015, when the administration tried to introduce outsourced vehicles.
Outsourcing, outsourcing everywhere
Outsourcing is a fashionable term in Russia. But for Russian doctors, it’s become synonymous with “catastrophe.” In the regions, the powers that be are making medical establishments abandon so-called “non-core functions” – whether they’re transporting and feeding patients, or the cleanup and disinfection of hospital premises. Yet these services haven’t become any better – or cheaper.
“Outsourced expenses for each patient stand at 130 rubles (£1.37) per day. Can you really feed a patient with that sum?”
Ufa’s ambulances were among the first victims of outsourcing. In 2012, Novokor, a company owned by Perm businessman Yevgeny Freedman and already operating in Kirov, Samara and Yekaterinburg, offered its services to the Ufa ambulance station.
Over the next three years, the company firmly established itself at three substations in Ufa – Demskaya, Kalininskaya, Sipailovskaya, and, partially, at the central station. Maternity ward in a Yekaterinburg hospital. Photo CC: Peretz Partensky / Flickr. Some rights reserved.Resistance began when Freedman, with full support from the administration, decreed that the Ordzhonikidze substation would also use outsourced vehicles. The Deistvye union, whose biggest member cell is at Ordzhonikidze, decided to resist. Doctors joined ambulance drivers in protest.
“We saw the results of outsourcing at other substations and became convinced that this ‘reform’ results in highly negative consequences for patients and poorer working conditions for drivers,” said nurse Yavgildina. “The outsourced vehicles only have stretchers and electrical outlets, whereas as ours are equipped to the gills, in accordance with all of the rules. Our drivers work 12-hour shifts, but the private company from Perm forces them to work 24-hour shifts… which is actually illegal.”
“We saw the standard labour contract between the Perm company and a driver, and were shocked,” added paramedic Mikhail Tishin. “They’re paid only 70 rubles (£0.74) an hour, and the driver is not allowed to complain about the employer, not allowed to contact media outlets, or even tell anyone about working conditions.”
Because of protests, the Ordzhonikidze substation was saved from outsourcing. But this novelty is meanwhile spreading to other branches of healthcare.
“In Ufa, most hospitals have already outsourced catering, but the food didn’t get any better,” admits the regional chapter of the United People’s Front. “For example, the hospital gets one ruble to feed one patient, but doesn’t need to pay extra to rent a canteen, or to pay cooks. All of that is included in the budget already. A company wins a tender, gets that same ruble – but now it must also pay cooks and pay rent. If we take all figures into account, we see that outsourced expenses for each patient stand at 130 rubles (£1.37) per day. Can you really feed a patient with that sum?”
An ambulance on call in a Novosibirsk suburb, 2015. Photo (c): Aleksandr Kryazhyov / visual RIAN. All rights reserved.In March of this year, local media reported that the health ministry of Bashkortostan plans to use outsourced (and expensive) medical equipment. Fans of outsourcing argue that a lot of such medical equipment is not used properly, as there aren’t enough qualified specialists to service it. Meanwhile, nobody is bothering to ask how much prices for high-tech medical procedures will rise.
A protest with tied hands
The hunger strikes and pickets at the Ordzhonikidze substation are so far the only protests by medical staff in Bashkortostan. But further dissent can’t be ruled out. Legal constraints on doctors mean that a secret protest is taking place – one that involves worsening treatment of patients.
“It’s hard for us to protest, since strikes are technically forbidden in our field,” said Ufa doctor Yevgeny Ionis. “The protest against deteriorating working conditions, as I have observed, is expressed by many medics in growing negligence in their work, so healthcare standards are falling.”
The Deistvye union recently publicised a story of how doctors at Ufa Hospital No. 22 refused to hospitalise a pensioner showing stroke symptoms, having literally forced him outside. The poor man spent over 24 hours outside in his wheelchair with no food. He was saved only when Deistvye activist and ambulance driver Dmitry Dumenko found out about the incident, became enraged, and called the police and journalists to see what was happening at the hospital.
The medical community has repeatedly discussed a shocking case in a Belgorod hospital, where a doctor beat a patient to death. “This, unfortunately, is not a unique incident,” Ionis said. “We also had a doctor in one of our hospitals in Ufa who cruelly beat patients. Of course, he was fired. All of this is actually a sign that medics are emotionally burned out. There’s a reason why all doctors must now be evaluated by a psychiatrist once a year.” “An ambulance driver holds the lives of doctors and patients in his hands”. A protest against outsourcing in Ufa, December 2015. Photo courtesy of the author.“Objectively speaking, such incidents will, unfortunately, increase in number,” said Deistvye’s Andrei Konoval. “Medical professionals are under a lot of pressure, they work twice or even three times as much as usual. According to our data, some doctors have an uninterrupted working day of 32 hours straight – including night shifts. Meanwhile their salaries, despite the bravado of health ministry reports, are actually falling – nominally and in real terms. People won’t act normally under these circumstances.”
The situation faced by the medical establishment results in a lack of qualified specialists. In February 2016, the region’s health ministry, for example, said that in 2015 the average rate of doctor availability in the republic was just 34.4%.
It’s a particularly poor showing, but indicators across the country as a whole are also disturbing. As doctor Guzel Ulumbekova found in her report to the All-Russian Pirogov Congress of Physicians, in 2015 there were 22% fewer practicing medics and 23% fewer hospital beds than national standards required. Even more worringly, the number of doctors in rural clinics across Russia is now 3.5 times lower than those in urban areas.
In 2015, the average rate of doctor availability in the region was just 34.4%
“According to our data, Ufa polyclinics have just half the required specialists” reports the regional branch of the United People’s Front. “Things are even worse in village hospitals and polyclinics. Medical school graduates don’t want to work in polyclinics due to low salaries, and don’t want to suffer, like their older colleagues, by working two jobs.”
“Ever year, 170 specialists in our field of medicine graduate from the local medical school, but after their final year, they immediately disappear somewhere else,” said Irina Kazakova, head of paediatrics at Ufa Hospital No. 22. “They come to us to do tryout shifts, stay about two months, and don’t come back – they go to work for private establishments.”
Passing the baton
In the last five and a half years – the tenure of the republic’s current head Rustem Khamitov – Bashkortostan has already seen three health ministers come and go. This ritual of “passing the baton” hasn’t improved workings at the ministry.
This January, local media reported that the regional prosecutor’s office filed an entire list of complaints against the local health ministry. Corruption offences included conflicts of interest, unlicensed plastic surgeries, and hiding profits. Mosaic to medical workers on a Soviet-era hospital in Ulyanovsk, Russia’s Volga Region. Photo СС: Yuriy Lapitsky / Flickr. Some rights reserved.Khamitov is constantly dressing down the health ministry in public. Last April, he came down on all spheres of the health ministry’s activities: “[In 2014] I received 800 complaints about healthcare, in this year, I am already dealing with 200,” he said. “People are most worried about quality of care, bureaucratic box-ticking, and negligent treatment of patients.”
Bashkortostan’s leader was especially incensed at the price at which healthcare institutions had to buy medicines, which he said can differ by twenty times the amount depending on the hospital.
After this tongue-lashing, the public awaited the dismissal of the region’s health minister Anvar Bakirov. It never came, but six months later, Khamitov again launched into another tirade against the ministry and medicine-buying practices.
It’s entirely possible that the health ministry will be dressed down in public again. But nothing will actually change – the system will not be changed via verbal abuse nor by making scapegoats of individual ministers. It’s a legacy inherited from the USSR and undermined the state bureaucrats and private companies of Russia today. Bashkortostan is just one example of a health system which is now in a deep malaise.
“This is what we see: scandals in the [medical] sector make it into the press, get noticed by the public, but this changes nothing,” concluded Yevgeny Ionis. “Our healthcare system is gravely ill, and if you want to break the vicious cycle, you have to start where it began – in the polyclinics and the turmoil in branches of government responsible for healthcare.”