POLICY AND PRACTICE
Mortalité par maladies non transmissibles dans la Fédération de Russie : de la législation à la politique
La mortalidad por enfermedades no transmisibles en la Federación de Rusia: de la legislación a la política
Marya Levintova1; Thomas Novotny
University of California, San Francisco, Institute of Global Health, 74 New Montgomery Street, Suite 508, San Francisco, CA 94105, USA
Political, social and economic transitions that occurred as a result of the regime change in Eastern Europe and the Russian Federation from the late 1980s to the early 1990s led to a sudden increase in mortality across the region, with more than 80% of deaths being attributable to preventable causes, such as cardiovascular disease, lifestyle factors and injuries. The Russian Federation has experienced some of the most dramatic population declines in the world. Countrywide health reforms have been implemented, although they continue to ignore the impact of the epidemic of noncommunicable diseases (NCDs) in the Russian Federation. Improvements in mortality patterns in the Russian Federation are possible only with the broader engagement of organized nongovernmental groups within the civil society that is strongly supported by Federal legislation to address NCDs. We discuss the Russian Federal legislation germane to the prevention and control of NCDs in the light of the current mortality crisis and suggest possible policy responses to this crisis.
Keywords: Chronic disease/mortality; Cardiovascular diseases/prevention and control; Legislation, Health; Health care reform/legislation; Health promotion/legislation; Smoking/legislation; Health policy; Russian Federation (source: MeSH, NLM).
Les transitions politiques, sociales et économiques qui se sont opérées en Europe de l'Est et dans la Fédération de Russie sous l'effet du changement de régime entre la fin des années 1980 et le début des années 1990 ont conduit à une augmentation brutale de la mortalité dans l'ensemble de la région, avec plus de 80 % des décès imputables à des causes pouvant faire l'objet d'une prévention, telles que les maladies cardiovasculaires, les facteurs liés au mode de vie et les traumatismes. La Fédération de Russie a vécu certains des plus forts déclins de population enregistrés dans le monde. Des réformes de la santé ont été mises en œuvre à l'échelle du pays, mais elles continuent à ignorer l'impact de l'épidémie de maladies non transmissibles (MNT) dans la Fédération. Face à ces maladies, seul un engagement plus large de groupes non gouvernementaux organisés au sein de la société civile, bénéficiant d'un fort soutien de la législation fédérale, pourrait améliorer les schémas de mortalité russes. L'article examine la législation fédérale actuelle se rapportant à la prévention et à la maîtrise des MNT à la lumière de la crise de mortalité vécue à ce jour et propose des réponses politiques possibles à cette crise.
Mots clés: Maladie chronique/mortalité; Cardiovasculaire, Maladies/prévention et contrôle; Législation sanitaire; Réforme domaine santé/législation; Promotion santé/législation; Tabagisme/législation; Politique sanitaire; Fédération de Russie (source: MeSH, INSERM).
Las transiciones política, social y económica que trajeron consigo los cambios de regímen en Europa oriental y la Federación de Rusia entre finales de los años ochenta y principios de los noventa produjeron un aumento súbito de la mortalidad en toda la región; más del 80% de esas defunciones son atribuibles a causas prevenibles, como las enfermedades cardiovasculares, factores relacionados con el modo de vida y los traumatismos. La Federación de Rusia ha sufrido una de las disminuciones de población más marcadas registradas en el mundo. Aunque se han implementado reformas sanitarias en todo el país, éstas siguen ignorando el impacto de la epidemia de enfermedades no transmisibles (ENT) en la Federación de Rusia. Sólo será posible mejorar las pautas de mortalidad en este país si se logra una participación amplia de grupos no gubernamentales organizados dentro de la sociedad civil, con el sólido respaldo de una legislación federal contra las ENT. Examinamos la legislación de la Federación de Rusia relacionada con la prevención y el control de las ENT a la luz de la actual crisis de mortalidad, y sugerimos posibles respuestas de política ante esa crisis.
Palabras clave: Enfermedad crónica/mortalidad; Enfermedades cardiovasculares/prevención y control; Legislación sanitaria; Reforma en atención de la salud/legislación; Promoción de la salud/legislación; Tabaquismo/legislación; Política de salud; Federación de Rusia (fuente: DeCS, BIREME).
The mortality crisis in the Russian Federation
There is a growing global awareness about the extensive negative effects of the economic, political and social upheaval that has occurred in the Russian Federation over the past two decades. The changes in demography of this powerful country (e.g. the rise in adult mortality and the decline in life expectancy; Fig. 1 and Fig. 2) pose serious dangers to the stability and future of the Russian Federation within the broader international community (1, 2). Some estimations of the extent of this crisis suggest that the population of the Russian Federation will decline to half of its current level by 2050 (3).
These population changes are mainly due to mortality from preventable causes, such as NCDs (including cardiovascular disease and certain neoplasms), alcohol abuse, road traffic accidents, and intentional and unintentional injuries (4, 5). Although life expectancy in the region has fluctuated over the past 40 years, marked declines occurred following the collapse of the Soviet Union in 1991 and the economic collapse in 1998 (Fig. 1). The life expectancy of adult males fell between 1987 and 1994 by 7.4 years to 57.5 years, rose to 61.3 years in 1998, and then fell again by 2.4 years in 2001. Female life expectancy fell by 2.6 years to 72 years between 1989 and 1994 (6–8). In 2001, men in the Russian Federation could expect to live 13.4 fewer years than their female counterparts (9).
Major changes in adult mortality were associated with gender inequalities in cause-specific mortality; about 80% of deaths were caused by NCDs (10). The rates of premature mortality among men have doubled since the late 1980s; 55.3% of all deaths in 2000 were from cardiovascular disease and 13% from neoplasms (11). Mortality from intentional and unintentional injuries has increased more than fivefold since 1991 (Fig. 2) (12, 13).
Comprehensive analyses of the underlying determinants of the increased mortality in the Russian Federation suggest that it was caused by the collapse of the social, economic and health systems; the high prevalence of unhealthy behaviours; and the lack of programmes for the prevention and control of NCDs (14–17). Furthermore, historical and cultural ideologies with regard to drinking, smoking and dietary behaviours, and non-participation in preventive measures also contributed to the epidemiological situation. Although policies for the prevention and control of NCDs and health legislation are not a high priority in many developed and developing countries, comprehensive government initiatives that utilize intersectoral action, provide clear strategies, and support the health-care system to address NCDs have shown notable results (18–20). The seriousness of the situation in the Russian Federation calls for a major reframing of health policy through a strong rule of law and development of a functional civil society.
In this article, we summarize current Russian Federal legislation in the light of the demographic crisis, and outline suggested population-based policy responses.
Legislative and policy responses
The Russian Government, although it is aware of the emergent demographic crisis, has been slow to acknowledge its significance through legislative approaches (21). Despite major efforts at health reform, which focused on improving health financing schemes, decentralizing and improving efficiency of health-care services, resolving inequalities in access and improving the availability of care, inefficiencies and inappropriate policies persist (22, 23). Health sector reforms in the Russian Federation since 1991 have consisted of various legislative acts and orders that operated at Federal or regional levels. These laws were guided by the revision of the Russian Federal Constitution in 1993 (24). The extreme economic crisis affecting the financing of health care was the primary concern during the initial phases of reform. Therefore most of the initial legislation focused on medical insurance and other factors related to the financing of medical care (25). A persistently slow and rigid change process with extremely limited resources has characterized 10 years of health reform in the Russian Federation. Political leaders have not been able to develop and maintain effective multi-sectoral cooperation between and within organizations and departments because they continue to perceive health as being solely a health sector problem (26). In the case of NCDs, healthier outcomes can be achieved only through cooperation between several sectors, such as labour, education, finance and health.
Nevertheless, health reform has been a guiding force in changing and adding to the legislative basis for addressing NCDs in the Russian Federation: 52 laws have been signed, first by President Yeltsin and then by President Putin, since 1991. These laws further defined health insurance, decentralization of health-care services, tobacco control, pharmaceutical issues, psychiatric health, organ transplantation, prevention and treatment of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and other policies (22, 27, 28). Although most of these legislative acts related to reorganization and restructuring within the health-care sector, some statutes mentioned prevention and control of NCDs (29, 30). Two examples that specifically address or have an effect on mortality from NCDs are the 1993 "Law on health protection of citizens of the Russian Federation" and the 2001 "Law on limitation of smoking" (28, 30).
The law on health protection of citizens of the Russian Federation has been the most significant health legislation enacted in the past decade (30). It serves as a foundation for the regulation of public health in the Russian Federation and has extensive statutes on the organization of health care, patient rights, the rights and the responsibilities of physicians, and coverage of medical care. It serves as the primary legislation that addresses prevention of chronic disease, and health promotion as a priority in Russian Federal health policy. Although this legislation focused primarily on the organization of health care, a number of statutes in this document pertain to disease prevention and health promotion, emphasizing health as a right of every citizen, stressing the importance of prevention, and assigning the responsibility for the development of prevention and health promotion programmes at the regional or local level. However, financing, organizational responsibility, evaluation, enforcement, and penalties for noncompliance with preventive measures are not clearly defined, making this law a declaration of desirable action, that lacks the systematic mechanisms necessary to achieve an effect on health outcomes.
A 1997 document on NCD strategy and policy development suggested a number of recommendations for the improvement of current legislation (31). These included:
- development of financial policy to support programmes for the prevention of NCDs;
- modification of legislation to focus on supporting social and environmental policies and programmes that promote healthy lifestyles;
- amendment of legislation with regard to the specific functions of the Ministry of Health and related public health departments; and
- formulation of laws and statutes regarding comprehensive intersectoral coordination, within and between various ministries and departments (31).
Although the document was highly regarded by government officials, its recommendations have not been implemented, suggesting a possible role for civil society in helping decision-makers make the prevention and control of NCDs a priority.
The 2001 "Federal law on limitation of smoking" sought to strengthen efforts to curb the epidemic of NCDs in the Russian Federation (28). More than two-thirds of men and a third of women in Russia are regular smokers and this law serves as the Federal tobacco control policy. Major issues addressed by this legislation are content of cigarettes (e.g. amount of tar), warning labels, advertising, marketing, and sales restrictions (28). Although this law was a crucial first step in Russian Federal legislation on tobacco control, it did not provide guidelines on implementation and enforcement. Earlier legislation on tobacco advertising in 1995 was based on the tobacco industry's voluntary code of conduct, and it included only minor restrictions on the content and placement of outdoor advertisements and on the timing of advertising broadcasts (32). Initial proposals to control tobacco advertising were successfully opposed by the tobacco industry, leading to the removal of this section. The advertising restriction does begin to control tobacco advertising, but its ambiguous wording makes enforcement impossible (33). Other sections of the bill were either removed in response to arguments from the tobacco industry (i.e. encouraging the production of films in which the actors do not smoke) or changed to make implementation and enforcement difficult (i.e. legislation on smoking in the workplace). Despite the weakening of the bill through tobacco industry lobbying, a ban on the sale of single cigarettes and packs containing fewer than 20 cigarettes, a ban on sales from vending machines, and enforcement of the previous voluntary agreement on health warnings were retained.
As well as the difficulties in implementation and enforcement, this law is particularly precarious because of the extensive involvement of transnational tobacco companies with the Russian Federal Government. According to some sources, these tobacco companies have invested over US$ 2 billion in the former Soviet Union since 1992 (34). There is no likelihood of legislation that could end this investment being passed, and given the prevailing market conditions, transnational tobacco companies will continue to reap the benefits for the foreseeable future (35).
Strategy and policy documents
Although much of the health-related legislation in the Russian Federation focuses on curative medicine rather than disease prevention, some policies on NCDs have been established through the 1994 and 1997 policy and strategy documents on non-infectious diseases (31, 36). These documents described the situation in the Russian Federation regarding NCDs and suggested several solutions to be considered at the Federal, regional and local levels. The 1994 document was the first of its kind in the Soviet Union or Russian Federation to report on population health status with respect to NCDs and external causes of mortality. It also described priorities for prevention of NCDs and strategies for health promotion. In many ways the 1997 document reiterated the 1994 strategy, but it also provided more concrete and inclusive guidelines for the development and implementation of policies on NCDs. For example, the 1997 document recommended the development of policies and legislation to support financing, organization and implementation of programmes for the prevention of NCDs.
The future of policies on prevention of noncommunicable diseases
The simple drafting of laws and policies is inadequate to address the complexity of NCD prevention and control in the Russian Federation. Therefore, a comprehensive strategy that includes financing, evidence-based interventions, professional training, multi-sectoral involvement and development of civil society resources is necessary. "Shock-therapy" legislation (such as Gorbachev's anti-alcohol campaign of 1985–87) has failed to generate public support for NCD policy in the Russian Federation (37, 38). Although this legislation is estimated to have prevented one million premature deaths among adult males of working age between the start of the campaign and 1993, the anti-alcohol campaign was terminated in 1987 in response to pressures from the public, the alcohol industry and from within the government itself, leading to an immediate surge of alcohol-related deaths (38, 39). Although this campaign might have offered a window of opportunity for major changes in legislation on alcohol, the general population was not prepared for such draconian measures. The failure of this programme further postponed any efforts to pass new laws related to alcohol policy, although discussions regarding future legislation on restrictions on purchasing age and advertising are continuing (personal communication, 2003).
Making prevention a priority
Prevention of NCDs remains a low priority in the Russian Federation; many people continue to be unaware or uninformed as to their personal responsibility for reducing risky behaviour. Most citizens of the Russian Federation seek medical care only when problems arise, instead of engaging in primary or secondary prevention practices (personal communication, 2003). In order for prevention to become important to the public and to decision-makers, an ideological shift may be necessary in the Russian Federation. Changing belief systems is a very slow and often intricate process, but it is often easier to achieve when the result is perceived to be appealing and profitable. Although the burden of NCDs has been demonstrated in the Russian Federation, primary prevention as a means to manage this burden is rarely marketed effectively to decision-makers and/or citizens (10, 19). Furthermore, although extensive data on the effectiveness of prevention are available, they are seldom transmitted to the lay public through advertising or media campaigns (e.g. on the dangers of smoking and alcohol abuse). In addition, epidemiological data on NCD prevalence, patterns, and changes are necessary to assist policy-makers in devising appropriate guidelines and strategies for the management of NCDs. Currently, the Russian Federation lacks the surveillance systems necessary for the collection of these data. However, the development of such systems is a necessary component of policy planning.
Payment for services
Although the law on protection of citizens of the Russian Federation explicitly states that regional and local public health authorities are responsible for developing prevention programmes, there are no provisions made for financing such endeavours. Although, some local authorities have set aside funds from Federal, regional and city budgets to support prevention programmes, the majority of public health departments do not support such programmes (31). Therefore, there is an urgent need for financing of health promotion and disease prevention programmes at the regional level in particular. Some suggestions from both international research and research within the Russian Federation have included the development of a taxation system that would allocate funds towards prevention programmes (40). These include: earmarking of Federal, regional and city funds; development of Federal legislation that would legitimize payment for preventive services; and development of tax incentives for those organizations or businesses that support NCD prevention programmes (31).
Technical and resource management
The Russian Federation is the largest country in the world, in terms of area of land, and the resources, training and expertise of the agencies involved in prevention activities vary considerably between and within regions. Numerous suggestions have been made regarding re-training of health professionals to adapt to the changing attitudes towards who should practise prevention (26). Furthermore, careful planning, supervision and evaluation of prevention programmes are needed to avoid unnecessary spending or loss of resources (both human and financial).
Increased involvement of non-health sectors
Prevention can only be achieved through the application of a range of strategies and the involvement of multiple stakeholders. The strategy and policy recommendations from the 1997 document call for the development of intersectoral connections in the monitoring, control and implementation of Federal health policies. Successful efforts in refining future policies will need to focus on collaboration between various sectors (e.g. health, industry, education and the legal system), because continuous collaboration is a necessary component of policy for the control of NCDs in the Russian Federation (31, 41).
Civil society and advocacy
Civil society in the Russian Federation is underdeveloped and narrow in scope: some of the nongovernmental organizations (NGOs) focus on infectious diseases such as HIV. However, there are NGOs (e.g. the Russian Public Health Association) that see the value of engagement at the policy level. A broader involvement of the community and a stronger advocacy movement are needed to enable the Russian Federation to inform its citizens about the significance of the current NCD crisis, and to suggest compelling alternatives to present policies to government decision-makers.
Furthermore, there is a need for an organized approach to community building that involves members of the community as health leaders. Such organized community groups could lobby the government to include health promotion and disease prevention as fundamental priorities in regional and Federal policies. There is hope that community alliances will form as the economy and the sociopolitical climate continue to improve, thus increasing the level of priority given to health.
Historically, the Soviet media were strictly controlled by the government. Regular presentations of health-related material were made to the public, but these were carefully screened and often politicized. Privatization of the media placed a substantial financial burden on public health departments trying to conduct health promotion campaigns or to provide information on risk factors. Although legislation on the protection of citizens of the Russian Federation describes access to health-related information as one of their major rights, there are no statements in any of the legal documents regarding the responsibility of the mass media to provide broadcast time or print space for health-related information. Without such opportunities, organizations with extremely limited funds will be unable to disseminate health-related information. Collaboration with the media as one of the key channels of health promotion needs to be encouraged and endorsed by the government.
The gap in life expectancy between males and females in the Russian federation has been widely studied (42). More attention needs to be paid to the potential causes and determinants of the significant differences in mortality and healthy life expectancy between the two sexes. Because most premature deaths among middle-aged men are attributable to cardiovascular disease and other sudden events, additional epidemiological analyses should be directed towards these causes of death. One aspect of policy in the Russian Federation that is substantially underdeveloped relates to priorities regarding various "at-risk" groups (e.g. the elderly, disabled people, women and children).
The current approach does not address the major issue of the escalating mortality among working-aged men. Furthermore, young and middle-aged men in the Russian Federation currently lack incentives to engage in healthy behaviour (personal communication, 2003). Younger men, who may suffer from fatalism because of the difficult economic situation in the Russian Federation, must also be a priority target group for Russian health policy. If the specific needs of this population are not addressed, a large proportion of the workforce will continue to experience deteriorating health, causing further economic crises resulting from ill-health and loss of human capital. There is a health crisis in the Russian Federation, and with appropriate legislation that is supported by civil society, this crisis can and must be mitigated (43).
We would like to thank Dr Stewart and Dr Dohan at the University of California San Francisco, USA, and Dr Kamardina at the National Centre for Preventive Medicine in Moscow, Russian Federation, for their useful comments on earlier versions of this manuscript.
Conflicts of interest: none declared.
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Submitted: 29 September 2003 – Final revised version received: 22 March 2004 – Accepted: 24 March 2004