The health crisis in Russia
Authors: Rifat A Atun
Journal: BMJ (2005)

Russia is one of the few developed countries where life expectancy has fallen in recent years.1 Russia's total life expectancy of 66 years lags behind that of Japan by 16 years, the European Union by 14 years, and the United States by 12 years. High mortality and morbidity from non-communicable diseases, along with a low birth rate, mean that Russia's overall population is rapidly becoming smaller and sicker. Reporting recently for the World Bank, Marquez and colleagues emphasise the gravity of Russia's health problems and argue that the crisis represents a “new pattern of the epidemiological transition that deviates from that experienced by a number of western countries where age-specific NCD [non-communicable disease] rates declined and life expectancy grew.”w1

Russia's population declined from 149 million in 1992 to 143 million in 2003, and in the next 50 years it could fall by 30% to 100 million. Compounded by rapid ageing of the population, this fall is increasing the dependency ratio (the ratio of the economically dependent part of the population—mainly those too young or too old to work—to the productive part) and producing an economic burden that Russia may not be able to afford, given that its gross domestic product (GDP) is the lowest of all the G8 countries.

Mortality for Russian men substantially exceeds that in countries with similar per capita income levels. For example, in Russia the probability that a 15 year old boy will die before he reaches 60 is double that in Turkey. Within Russia, mortality varies fourfold between regions, and differences in life expectancy can be as large as 18 years. The picture is different for women, who live about 14 years longer than men in Russia—a much greater gender gap than the average of eight years in other G8 countries (Canada, France, Germany, Japan, Italy, Russia, the United Kingdom, and the United States).

Morbidity and mortality from non-communicable diseases and injuries—the leading causes of death—in Russia are three to five times higher than average rates in the European Union. At 994 per 100 000, Russia has one of the highest death rates from cardiovascular disease in the world, accounting for 52% of all deaths nationally each year. Similarly, the rate of traffic injuries, at 20.6 per 100 000, is double that in EU and G8 countries, and the rates for cancer mortality, homicide, and suicide far exceed EU levels.

In 2003, deaths from cardiovascular disease, cancer, and injuries accounted for 15.2 million lost years of potential life. Around 75% of deaths and 46% of the disability adjusted life years (DALYs) in Russia can be attributed to high blood pressure, high serum cholesterol, and tobacco use. Six out of 20 men smoke, but alcohol is also a big killer, accounting alone for 16.5% of the total DALYs lost in 2002. In 2004, about 70% of men and 47% of women were drinkers, with spirits comprising three quarters of the total alcohol consumption.

When combined with the stresses related to economic transition—collapse of the social safety net, lack of strict road safety measures, decline in fruit and vegetable consumption, sedentary lifestyles, and growing prevalence of obesity—these risk factors create a highly unfavourable health environment. Furthermore, when the burgeoning epidemics of HIV infection, multiple drug resistant tuberculosis, intravenous drug use, sexually transmitted disease, and hepatitis C are also taken into account, the severity of Russia's health crisis is magnified substantially.2 w1

In 2005, deaths from cardiovascular disease and diabetes will cost Russia US$11.1bn in national income (1% of GDP), and this cost will increase by 2015 to $66.4bn (5% of GDP). Cumulatively, in 2005-15, these losses will amount to $303.2bn, 10 times those in the United Kingdom.3

Most non-communicable diseases and injuries can largely be prevented by integrated approaches to reduce the main risk factors, especially when population based public health strategies are combined with healthcare interventions targeting “highrisk” individuals.w3 If such interventions were to reduce mortality from cardiovascular disease in Russia to EU-15 levels (those in the EU before it expanded), total life expectancy would increase by 6.7 years. Furthermore, reducing mortality from non-communicable diseases in Russia to EU-15 levels by 2025 would bring economic benefits equalling 3.6-4.8% of the 2002 Russian GDP and overall welfare benefits to the country amounting to 28.9% of the 2002 Russian GDP. Improving Russian adults' health to levels in the EU-15 countries by 2025 would increase per capita GDP by an additional $9243, if such improvements were not realised.

For Russian doctors and policy makers, the choices are clear. The Russian health system, which is dominated by hospitals, vertical systems for service delivery, and focus on cure rather than prevention, must be reformed to create intersectoral approaches to public health and a well developed primary care system that emphasises health promotion and prevention of non-communicable diseases.

For EU and G8 leaders a stable, healthy, and economically strong Russia is strategically important. In 2006 Russia will assume the rotating presidency of the G8. President Vladimir Putin has an opportunity to lead the global health debate and keep health high on the G8 agenda. In particular, he could extend development assistance for health so that it is allocated not just on the basis of child mortalityw4 but also takes account of communicable and non-communicable diseases in eastern Europe and central Asia, where development assistance has been much lower than that warranted by the level of development.w5

But first Russia must kick start the transformation of its own health system. It needs to strengthen public health and primary health care, rectify deficits in governance,4 overcome structural and financing barriers,5 close the legal gaps that hinder public health responses,6 and create incentives to motivate stakeholders and encourage investment in evidence based innovative health technologies. In his state of the nation address in 2005, President Putin said, “the success of our policy in all spheres of life is closely linked to the solution of most acute demographic problems.”w6 Next year G8 and EU leaders have a rare window of opportunity to support him in driving through the health reforms Russia most desperately needs.