Print Friendly and PDF
only search openDemocracy.net

Scaling back on healthcare may start with Russia’s migrants. But it won’t end there

The Russian state has absolved itself from providing social services to migrant workers. Are its own citizens next? RU

A visitor to a multi-purpose migration centre in the village of Sakharovo, outside Moscow, where social services are offered to labour migrants. This complex, the largest such centre in the country, was visited by Moscow mayor Sergey Sobyanin. Photo (c): Maxim Blinov / RIA Novosti. All rights reserved.Russia has still not come to a final decision on its policy towards migration, despite having produced a raft of strategic government documents on the subject. During the 2000s the country experienced a “demographic dividend”, with a surplus in its working age population, along with fewer children and elderly people. However, since 2009 the supply of labour has been dropping every year relative to demand. To sustain economic growth, external labour supply sources are increasingly in demand — namely, migrant workers.

Recent figures show that there are around seven to eight million foreign workers in Russia. Most of them are from Central Asia — Kyrgyzstan, Tajikistan, and Uzbekistan. These countries will also supply the future of migrant labour in Russia. Many migrants come from rural areas; the large Russian cities where the demand for their labour is concentrated represent their first ever experience of city life. Labour migration is, as a rule, linked to downward social mobility: the education they have received in their home countries is rarely reflective of the jobs they have to take here.

Most migrants from Central Asia are men: women make up less than a fifth of those from Tajikistan and Uzbekistan, and fewer than 40% of those from Kyrgyzstan. Those from Kyrgyzstan are also more likely to be young: their social norms dictate that women should marry before the age of 25 and start having children in the first three years of marriage. They are expected to marry “at the right time”, have children, take responsibility for the health of the marriage — and earn a living. All this takes place in a situation where few are educated about sex, with a consequent lack of contraceptive measures.

The regulations on healthcare for foreign citizens that came into force in Russia in 2011 practically deprives female migrants of any right to qualified medical help during pregnancy and childbirth. And as research that I carried out at Moscow’s School of Social and Economic Sciences and Manchester University shows, the new law affecting foreigners is also the clearest reflection of the changes in Russia’s social welfare sytem as regards its own citizens.

“They’re flooding into our country and now they’re having babies”

In 2009, Aidjan left Bishkek, the capital of Kyrgyzstan, to join her husband in Moscow. He had lived there for four years and had received Russian citizenship. He’d bought a car, was working in the construction industry and could provide for a family. Once in Moscow, Aidjan got pregnant with her first daughter almost immediately. Friends of her husband told her that if she applied to the Ministry of Health, she could get free antenatal care at a women’s clinic. She applied, brought along the necessary paperwork and gave birth in a local maternity ward.

But by the following year, when she was once again pregnant, this arrangement was no longer in force. She spent the first months of her pregnancy in Moscow and thought about going to a private antenatal clinic, but the cost was prohibitive and she didn’t trust the “Kyrygyz” health centres that were beginning to spring up, although they were cheaper. One day, when she went to one of these clinics for a check up, she was told that the foetus was “defective” and that she needed an abortion. She was unconvinced: “Kyrgyz women are the only ones who come to this clinic, because the staff are all Kyrgyz here. They might have lied: perhaps I don’t need the abortion.”

To check the diagnosis, Aidjan went to another, non-Kyrgyz clinic, where she was told that everything was OK. In the end she flew to Bishkek for her antenatal care and returned to Moscow, with all the right papers, to give birth. These “international” antenatal care stories are fairly rare: not everyone can afford to travel back and forth, and not all women are convinced that such care is even necessary. Neither was Chinara, a Kyrgyz woman who came to Moscow in 2004.

Maternity ward in a Ekaterinburg city hospital. Photo CC: Peretz Partensky / Flickr. Some rights reserved.When I met her, Chinara was 36. She lives in Moscow with her husband and three children, the youngest of which was born in Moscow and the two elder ones in Kyrgyzstan. She first arrived in Moscow from a village in the Batken Region of southern Kyrgyzstan: her husband had already been in Moscow for a year and was working in construction; there were no mobile phones then so they had to go to the post office to talk to one another. Chinara missed her husband, and life in the village was difficult without a husband – she had to lug coal and firewood around by herself.

When she got pregnant in Moscow, Chinara kept on working and looking for jobs. She didn’t give any thought to seeing a doctor, as she felt fine, didn’t think of her pregnancy as an illness and so saw no need for any medical services.

“I didn’t go for a check up – we were short of cash,” she says. “Once you start, it’s ‘go here’ and ‘go there’. I felt fine, had no pain or anything. I even postponed a scan where I could have found out the sex of the baby. I didn’t know whether I was having a girl or a boy. I kept putting it off, and then I just gave birth.”

The “migrant” maternity hospital was notorious not only because you could catch an infection, but also for the attitude of the medical staff

She was surprised when she went into labour, as according to her dates it should have happened later, and she had planned to return home to Kyrgyzstan for the birth. She also hadn’t completed a prenatal record, a document with information about the expectant mother based on her antenatal care, including scans. At the time, mothers without this record were sent to a maternity hospital with an infectious disease department, which was notorious among migrant women. Another woman I spoke to told me that women would even bribe the emergency doctors to take them to any other maternity ward: “There’s this maternity hospital with an infectious disease department, so apart from the maternity wards there are other sick patients and elderly people, not to mention the drunks in the sobering-up room. So my mum gave the doctors 500 roubles not to take me there.”

The “migrant” maternity hospital was notorious not only because you could catch an infection, but also for the attitude of the medical staff. Chinara arrived at night, and says she found herself in a horror film: there were lots of women giving birth and very few staff: “a doctor comes along to examine you, and all the other women start screaming ‘Help me, doctor’, and the doctor shouts back, “there are lots of you and just one of me!” she says. “Everyone’s screaming, everyone’s in pain… I’m screaming too, and we can’t hear one another.”

Mother with child. Sary-Tash, Osh Region, Kyrgyzstan, 2010. Photo СС-by-2.0: Evgeny Zotov / Flickr. Some rights reserved.When Chinara went into the second stage of labour she was wheeled round to the delivery room, where the midwife started trying to hurry her up: “Come on, let’s get it out, it’s the end of my shift.” Chinara pushed as hard as she could and gave birth to a daughter, after which she was pushed out of the delivery room on a trolley into a corridor, where she and several other new mothers had to wait several hours before they were given beds in a ward: “they’re busy with births in there, they don’t have time to wheel you round the wards.” When the doctors examined her, says Chinara, they said: “You came here to earn money and then you go and have children. Why do you have these children?”

I heard similar tales from other people. Ainura had her children in Bishkek, but witnessed how a relative was treated in Moscow: “When I saw that, I scolded her,” she says. “You’d have been better off, I told her, going back to Kyrgyzstan, and paying for proper treatment - not this attitude, like you’d had sex under a fence somewhere. When you don’t have the right passport, they treat you badly in maternity hospitals, even if you pay. So a lot of women go home to have their children.”

Unwanted patients

Chinara and Ainura’s stories don’t just reveal a lot about the medical professionals’ racist attitudes, but also highlight structural problems — the paradoxical situation facing Russia’s healthcare system. Before 2010, legally employed foreign citizens had the right to take out an Obligatory Medical Insurance (OMI) policy and have treatment in state medical facilities, while their employer paid their OMI contributions.

However, in 2010 the employer’s contribution element was abolished and migrants lost their access to state medical services – whether or not they were in work. Up to then, Moscow’s Health Department had accepted applications from foreign women to register with women’s health clinics for their antenatal care, but from 2010 on this ceased to be possible. The very formula, “accepted applications” suggests that the department regarded this “service” as something marginal and exceptional and one from which migrants were implicitly excluded, making them file a special application to access it. Female migrants were simply seen as a bottomless, precarious workforce, not individuals with their own lives and needs which continued when they arrived in Russia.

This change in attitude to foreign citizens took place against the backdrop of a general reform of Russia’s health service, in which medical establishments adopted a per capita financing system. As a result, help offered to patients without an OMI policy (for whom a hospital wouldn’t receive any money) were the responsibility of the hospital management itself. As the medical director of one Moscow maternity hospital explained: “Our salaries will now come out of the OMI fund. And not only salaries, but food, bedding and so on. I have a staff of 140, and a tiny cost margin – so how can I make enough money to pay my staff? So now everyone will refuse to accept migrants arriving in ambulances. If they need our services, let them pay!”

“I have a staff of 140, and a tiny cost margin – how can I make enough money to pay my staff? Now everyone will refuse to accept migrants arriving in ambulances”

In other words, directors of medical facilities are faced with a dilemma: either help people and break the bank, or refuse to and be dragged through the mud by the media, like the case in Primorye in 2013 where an Uzbek woman almost gave birth in the porch of the maternity hospital as the staff refused to take her in.

Of course, the medical services for which a hospital would or wouldn’t be refunded by the state (for treating patients without OMI policies) had to be formalised and a list drawn up. But a clear policy on this took quite some time to complete, but even when it was completed it still raised questions: for example, the distinction between “acute” and “urgent” situations was not clearly defined, particularly where childbirth was concerned. In 2013, new regulations were drawn up, obliging medical staff to provide help to any patient, so long as it could be classified as urgent. Regional budgets didn’t always take into account the cost of treating patients who had no OMI policy, which exacerbated the problem.

“Migrant mothers have overrun Moscow’s maternity wards!” claim several Russian TV news programmes. Image still via YouTube / NTV, 2012. Some rights reserved.A growing commercial sector catering to migrants benefitted substantially from these changes: for example, the migrant community started opening their own clinics, staffed by doctors from Central Asia. For some migrants, this was a welcome development – treatment was cheaper and there was no language problem. Others, including Aidjan, didn’t trust the new clinics.

Meanwhile, reports started appearing in the media about how migrants were exploiting emergency facilities (where treatment is free to all by law) and indulging in “medical tourism”. Central Asian women, they claimed, were coming to Russia expressly to give birth for free. The interviews I conducted in 2010-11 didn’t confirm this, and Moscow Health Department statistics for 2013 give the number of births to foreign women as 7% of the total, and not a third, as some journalists claimed.

Unilateral neoliberalism

In 2016, the Russian government made citizens of other countries responsible for their own healthcare. From 1 January 2016 every foreign citizen applying for a work permit had to produce a voluntary medical Insurance policy, or an undertaking from their employer to provide whatever medical treatment they required. In other words, over the last seven years, Russia has gradually withdrawn from any obligation to provide any health-related services: making migrants themselves responsible for them, increasing their everyday expenses and creating a large, precarious market for private insurance firms.

In abdicating its responsibility for the welfare of foreign citizens working on its territory, the Russian government follows neoliberal model which is at work elsewhere

This tendency – to make foreigners more responsible for themselves and provide extra income for third parties – isn’t restricted to healthcare. As a recent study by the Russian Presidential Academy of National Economy and Public Administration shows, the introduction of an obligatory exam in Russian language, history and legislation (also in force since 1 January 2016) is part of the same trend – to create extra income for universities at migrant workers’ expense. The idea was supposedly to help migrants integrate, but the exam does little to help this process. Presenting this exam as a means of promoting integration with the local population, without undertaking any systematic measures to do so, effectively makes them responsible for their own integration, as it has done in the health sector.

In abdicating its responsibility for the welfare of foreign citizens working on its territory, the Russian government is following a neoliberal model which is at work in other countries as well – in the USA, especially, but also in the countries of the “Global South”. How it works is that migrants are accused of abusing the social services of the host country, while at the same time an ethical panic is whipped up over “illegal migration”. Foreign workers are held responsible for structural social problems, which often leads to restricted access for them to social welfare systems, healthcare and education.

A migrant in a temporary tent camp at Golyanovo, Moscow Region, 2013. Photo (c): Andrei Stenin / RIA Novosti. All rights reserved.At the same time, foreign migrants are an ideal, flexible workforce for a neoliberal state: if the economy is growing they are an instant solution to any labour shortfall, while at a time of economic crisis they can be equally rapidly removed. The host country has no responsibility for migrants’ social welfare: but plenty of sanctions against them – a closed border, deportation or administrative expulsion.

Employers can hire migrants on the basis of a service contract, rather than a Labour Code, which means they can circumvent both the requirements of employment legislation and any contractual agreement with the employee: migrants very rarely set up trade unions or assert their legal rights.

In Russia’s unilateral neoliberalism, there is nothing to mitigate the increasing inaccessibility of the social welfare system. And that doesn’t just apply to migrants

While following the neoliberal economic model, Russia’s legislators are forgetting one thing: this model implies not only a rejection on the part of government of any “social burden”, but also a number of other policies, from consolidating the institution of private property to the lowering of taxation. At least in theory, these encourage a general growth in prosperity thanks to increased individual business activity and neutralise, to some extent, the effects of state withdrawal from many other sectors.

Russia’s unilateral neoliberalism doesn’t entail any such neutralising activity: there is nothing to mitigate the increasing inaccessibility of the social welfare system. And this doesn’t just apply to migrants. Unilateral neoliberalism widens the general gap between rich and poor and in the end affects all members of society — sooner or later every citizen who finds themselves in hospital will feel themselves to be an “intruder”.

Translated by Liz Barnes.


We encourage anyone to comment, please consult the
oD commenting guidelines if you have any questions.