1000 km away

Bodaibo is a town in the Irkutsk region. Recently, 30 people there decided to write to President Putin. They embarked on this initiative at their peril, because in Russia letters to the head of state usually get passed down the line: the President's outer office sends it to the local government; it is then referred to the administration of the town where the letter originated. And the administration – usually – deals with the complainants; more rarely with the complaint.

This letter concerned a very basic problem: the inaccessibility of free medical care guaranteed by Article 41 of the Russian Constitution. According to Article 41, 'each citizen is entitled to healthcare and medical assistance which shall be rendered free at the point of delivery in public healthcare institutions, with expenses being covered from the appropriate budget, insurance contributions and other income.'

The people from Bodaibo wrote that, 'the central district hospital and the out-patient clinic have no more than half the doctors they need: there are no cardiology, oncology, endrocrinology, psychiatry and urology consultants. Patients are referred to medical institutions in Irkutsk, which is about 1000km away as the crow flies. Tickets cost 10,500 roubles [£147] in each direction, more than 20,000 roubles there and back, so how can there be any talk of free, accessible treatment? Salaries and pensions in the town are small and disability pensions of 6,000-7,000 roubles are wretched.'

Each Russian citizen is entitled to healthcare and medical assistance free at the point of delivery

Svetlana Melnikova lives in Bodaibo. She says that the average wage there is about 30,000 roubles [£419]. 'My husband's and my salaries together amount to 55,000 [£768]. We spend almost 40,000 on food, our communal flat, loans and any other personal expenses. So you can see that to go to a doctor we would have to save up two salaries. We have been saving for six months and now have 60,000 roubles put aside in case we have to go to the doctor.'

Until 2012, flights to Irkutsk were considerably cheaper. 'Until the summer of 2012, there were three airlines (Yutair, Angara and IrAero) flying to Irkutsk and the prices were held at relatively moderate levels – in May of that year a ticket on Yutair cost 5790 roubles [£81]. But when Sergei Yeroshchenko (he owns the holding company Eastland, of which Angara is an subsidiary) was appointed governor, Yutair was squeezed out of the Bodaibo-Irkutsk freight and passenger market. After this, Angara and IrAero divvied up the market in such a way that the cost of a ticket increased by 54% in November 2012, to 8,945 roubles, and in October 2013 increased again to 10,500, an 80% hike over the original ticket. It bears all the hallmarks of a cartel, though for some reason neither the prosecutor nor the Federal Antitrust Service has evinced any interest in it at all.'

Another resident, Kirill Loginov, bemoans the fact that Bodaibo can only be reached by plane. 'There's no railway and the road takes you through the republic of Buryatia, but people registered in the Irkutsk region are not allowed to cross the border.'

The signatories to the letter say they would be delighted to talk about their problems to the regional authorities but the mayor, Yevgeny Yumashev, has distanced himself from local problems by constructing a high fence around his dacha and avoiding all contact with people in the town; other officials find good reasons not to visit it.

The mayor has distanced himself from local problems by constructing a high fence around his dacha.

At the most recent election to the Irkutsk regional legislative assembly, in September 2013, the extremely low turnout (12.43%) was the people of Bodaibo's way of showing their disgust with many years of unsolved problems and a complete lack of concern on the part of their various governors. During the election campaign not a single candidate held a meeting with the Bodaibo electorate. To avoid negative reaction in the press, the assistant prosecutor for Bodaibo sent a letter to the editors of the district newspaper asking that 'any article on the subject of the forthcoming election to the Legislative Assembly on 8 September 2013 should be emailed to the prosecutor's office for approval.'

Local healthcare centres in Russia face closure. (c) Roma Yandolin / Demotix.

'Accessible environment 2011-2015' is a regional programme that allows people with disabilities to travel for treatment to Irkutsk. Sergei Maltsev is in a wheelchair. In September Maltsev needed to see a cardiologist, so he applied to social services for funds to buy a ticket. He was told, very rudely, that there was no money. Apparently the regional Irkutsk administration had set a limit of 600,00 roubles for all the people in Bodaibo with disabilities – and there are more than 1,000 of them – which means that only 30 tickets can be provided in any one year.

Bodaibo is the centre of the gold mining industry in Russia; and has no money.

This makes people very cross. Bodaibo is not a village: it has a population of 14,000 and is the centre of the gold mining industry in Russia, bringing in some $26-31 billion a year. But Bodaibo sees none of that money.

'The problem is the Russian tax system,' says an official in the Irkutsk regional government, who did not wish to give his name. The gold mining companies working in Bodaibo are not registered in the town. They are registered in Moscow, and taxes are paid there. So the region has no money. This year's budget shortfall is 14.9 billion roubles and next year's is planned to be 10 billion. Western sanctions mean that the state is reducing expenditure on healthcare, education and other social costs, so the forecast is anything but cheerful. There is no question of the situation improving in the next few years.'

Lack of medication

In small communities the situation is even worse. The village of Krasnoye is in the Darovsky district of the Kirov region, 57km from the village of Darovsky, the regional centre; and 280km from Kirov.

Svetlana Krachova is the only doctor, not only in Krasnoye but in the whole of the Luzyansk rural area, which comprises 21 communities. Krachova has 2,000 people on her list.

'The difficulties are endless,' she says. 'The first and main problem is the lack of medication: at the moment we only have iodine and normal saline for the drip unit. And some bandages. The next delivery is in three days' time, so I hope that nothing happens before then. As a rule people have to buy their own medicine at the chemist, though that too is threatened with closure because it brings in less than 250,000 roubles a year, which is not profitable enough. '

Krachova says that when people come to the hospital the most common complaint is pains in the muscles and joints. 'Work here is mainly physical – forestry and farming. Forestry is particularly tough because there are few people and the work is very hard. Two to three people are needed to move each log. Do you know how heavy they are? My son went to work at the sawmill: after six months he had to stop because of his back. He is 22. We have no medication for cases like his. There are no ointments in the deliveries because they are not on the federal list of free medication. Painkillers are, but they're hardly the solution.'

Krachova is critical of healthcare policy in Russia. 'Even in the 1990s there were neighbourhood health centres in most villages,' she says. 'Now they have completely disappeared. If something happens in Krivets, a village 8km from us, no one will be able to give any medical assistance until I get there and sometimes each minute is vital. If you think about it, an ambulance is supposed to arrive within 20 minutes, but our nearest (with all the essential equipment) is in the district centre, 60km from here. At best they will only get to us in 40-50 minutes after we call them out, but the quality of the roads means they will almost certainly take longer.'

'Even in the 1990s there were neighbourhood health centres in most villages. Now they have completely disappeared’

The disappearing hospital

The village of Morki is a district centre in the republic of Mari El. Here the hospital is being closed.

According to local people, 'in 2006 this hospital had 320 beds. In October 2013 there were 180. Now they are trying to close down 140 more.'

'The maternity department has been closed,' says Nina Yemelyanova from Morki. 'Pregnant women have to travel to Yoshkar-Ola, 120km away, which takes two hours on a road that was last asphalted in the 1980s. You can imagine the potholes. So many maternity units have been closed down in the republic, that there are not enough beds in Yoshkar Ola wards. This means that women about to give birth have to stay with friends or in a hotel until they go into labour. The worst thing, though, is that the Morki central district hospital there doesn’t have an obstetrician, and the impossibility of getting a woman in labour to a maternity unit has already resulted in two fatalities. In one case the mother (before she arrived at the hospital) and in the other, the child.'

Morki people know why their hospital does not have enough consultants.

'No one wants to come here for 6,900 roubles [£96] a month,' says Yelena Mikhalyova, formerly a nurse at the hospital. 'I worked there until February this year and my salary was 5,200 roubles a month. This is only just above the minimum wage [4,800 roubles – £67]. Then my post was cut, together with another ten nurses, and now there are only seven junior medical staff in the hospital. And remember, there are 32,000 people living in this district! Rural district hospitals have been cut, no one wants to come here, and we can't help because there aren't enough of us.'

The closure of the neighbourhood health centres has dealt a colossal blow to Russian healthcare. Before 2011, these centres were funded from the regional budget. But that same year saw the presidential programme for modernising healthcare stipulate that all neighbourhood health centres and rural district hospitals should be funded by the Fund of Mandatory Medical Insurance, one of the state budget funds. This fund required medical institutions to treat no less than 3,600 patients per year, leading to many rural district hospitals closing. There are no statistics on the closure of medical institutions, and the figures vary according to region: in the Falensky district of Kirov region, for instance, 5 out of 27 neighbourhood health centres were closed as a result of the reforms; in the Olenin district of the Tver region the figure was 20 out of 27.

It is clear though that the Russian government has no intention of investing serious money in healthcare. The 2015 healthcare budget is 406 billion roubles (in 2014 the figure was 462.5 billion roubles). The defence budget for next year will be 2.9 trillion roubles.