IR-04-021 / June 2004 Policy Pathways to Health in the Russian Federation Edited by Landis MacKellar, Elena Andriouchina, and David Horlacher IIASA Policy Pathways to Health in the Russian Federation Edited by Landis MacKellar, Elena Andriouchina, and David Horlacher IR-04-021 June 2004 Interim Reports on work of the International Institute for Applied Systems Analysis receive only limited review. Views or opinions expressed herein do not necessarily represent those of the Institute, its National Member Organizations, or other organizations supporting the work. International Institute for Applied Systems Analysis – Laxenburg, Austria Telephone: +43 2236 807 – Telefax: +43 2236 71313 – Web: www.iiasa.ac.at Contents 1. Introduction ............................................................................................................... 1 2. Welcoming.................................................................................................................. 4 Welcoming remarks, Landis MacKellar ...................................................................... 4 Welcoming remarks, Natalia Rimashevskaya.............................................................. 6 3. Workshop Proceedings ........................................................................................... 10 Issues Overview, Landis MacKellar .......................................................................... 11 Russian Mortality Fluctuations since 1980, David A. Leon ....................................... 28 Health Care Provision and Financing, Sergey Shishkin ............................................. 44 The Public-Private Split in Health Care Systems, Les Mayhew................................. 55 Alcohol, Alexander Nemtsov...................................................................................... 66 Smoking, David Rotman ............................................................................................ 73 Crime and Violence, Yuri Andrienko ......................................................................... 81 Homelessness, Svetlana Stephenson .......................................................................... 90 HIV/AIDS, V.L. Fuller............................................................................................. 100 Reproductive Health, Elena Andriouchina............................................................... 117 Suicide, Ilkka Mäkkinen ........................................................................................... 125 Health, Hopelessness, and Social Norms, Larry Willmore ...................................... 136 4. Policy Recommendations and Conclusion, David E. Horlacher, Landis MacKellar and Elena Andriouchina............................................................ 145 5. Annexes................................................................................................................... 152 Annex 1. Program.................................................................................................... 153 Annex 2. List of Participants .................................................................................... 155 i Abstract “Policy Pathways to Health in the Russian Federation” was the name given to a project implemented in 2002-04 by IIASA in collaboration with the Institute for Socio- economic Studies of Population of the Russian Academy of Sciences. The core activity of the project was organizing a workshop, held at IIASA in September 2003, at which international and national researchers and policy makers shared information and insights. Through workshop papers and discussions, sources of the poor health situation in Russia ranging from bad health behaviors to inadequate health care financing were discussed and analyzed. The focus throughout was on possible policy responses. This IIASA Interim Report presents the Proceedings of the Workshop, followed by the workshop program and list of participants given as Annexes 1 and 2. The presentations published here are condensed versions of project papers available at the workshop web site http://www.iiasa.ac.at/Research/RMS/TACIS03/?sb=19. ii Acknowledgments The workshop whose proceedings form the core of this IIASA Interim Report was organized by the International Institute for Applied Systems Analysis and the Institute for Socio-economic Studies of Population of the Russian Academy of Sciences with the support of the European Commission (TACIS Seminars and Conferences, through EuropeAid/114135/C/G/TAC), the Austrian Federal Ministry for Education, Science and Culture, and the Russian Committee for Systems Analysis. The organizers are especially grateful to Dr. Judith Shapiro of the New Economic School, Moscow and Dr. Serguei Sourkov of the Independent Institute of Social Policy, Moscow, for helping to arrange background interviews. iii About the Authors Landis MacKellar is a scientist at the International Institute for Applied Systems Analysis and the Vienna Institute of Demography. He is also a member of the Health Economics Centre at City University, London, UK. Elena Andriouchina, MD, is a scientist at the Institute Socio-Economicheskich Problem of Narodonaselenia Rossiiskoy Akademii Nauk (Institute for Socio-Economic Population Studies of Population) of the Russian Academy of Sciences, Moscow. David Horlacher is Professor of Economics at Middlebury College, USA. iv Policy Pathways to Health in the Russian Federation Edited by Landis MacKellar Elena Andriouchina David Horlacher 1. Introduction The goal of the IIASA-Russian Academy of Sciences project “Policy Pathways to Health in the Russian Federation” was to improve the long-term health of the Russian population through a better understanding of the causes of current high levels of mortality and morbidity in the Russian Federation and the policies and means to address them. The central activity of the project was holding an international workshop of the same title at IIASA in Laxenburg, Austria, on 19-21 September, 2003. The immediate goal of this workshop was to present preliminary work on various health issues and to explore a research agenda with the following objectives: 1) Identify adverse health behaviors responsible for excess deaths and morbidity and current policies aimed at controlling them (examples include alcohol abuse, road accidents, high risk sexual behaviors, poor diet, stress and so on). 2) Consider the wider impacts of excess morbidity and mortality on the Russian economy (e.g., lost output, lower productivity) and also the impacts on current health care reforms and financing. 3) Consider how policies to reduce adverse health behaviors can be made to work more effectively by reviewing their impact, scope and consistency, and identifying alternative and complementary policy pathways. 4) Bring together the main stakeholders involved in policy design and delivery, to understand their individual contributions, how they interact and contribute directly or indirectly to the overall policy aim (e.g., a reduction in infectious diseases, road deaths, or homicide). The workshop was aimed at three main groups: researchers working directly in the area including, but not limited to, economists, sociologists, and medical demographers in the public health community; policy advisors in Ministries; and political decision makers. Target groups were selected based on three criteria: those having (1) a strategic overview of the issues; (2) a research track record in relevant areas of policy; and (3) technical expertise in economics, medical demography and health financing. This IIASA Interim Report presents the Proceedings of the Workshop, followed by the workshop program and list of participants given as Annexes 1 and 2. The 1 presentations published here are condensed versions of project papers available at the workshop web site http://www.iiasa.ac.at/Research/RMS/TACIS03/?sb=19. A few presentations, available as PowerPoint presentations but not as papers, are to be found on the web, but not in this Report. Among the objectives described above, significant progress was made regarding Objectives (1), (3), and (4); less so regarding Objective (2). The reason for this is that it became clear during the round of expert interviews that little work has been done in this area apart from HIV/AIDS. The lack of work in part reflects scarcity of data and disagreements on costing procedures to be applied. Further, the lack of capacity to carry out multi-disciplinary studies, reflected in the low number of economists with some training in health, health care specialists with some training in economics, etc., also plays a role. Under these circumstances, it appeared wiser to concentrate on documenting causes of poor health and policy responses. The project also pursued a number of subsidiary objectives: • Raising the awareness in the policy community of the diversity of policy interventions that can affect health, and the need for better co-ordination, measurement and evaluation. Given the researchers and policy practitioners who participated and the range of health problems explored, there is little question that awareness was raised regarding the diversity of policy responses. Discussions ranged from the control of alcohol to epidemiological screening and surveillance; from accident prevention to broad measures to reduce corruption and the feelings of powerlessness that it engenders; from health care finance to measures to promote mother and child health, etc. A theme that emerged repeatedly during the workshop was the lack of agreement