Demographic crisis in Russia
The decline in fertility is contributing to a rapid aging of the Russian population. Between 1959 and 1990, the number of persons aged 60 and over doubled. As a result, at the beginning of the 1990s, the proportion of the population aged 60 or over reached 16 percent. This figure will reach 20 percent by 2015. By that year, nearly one of out of every three people over 60 will be 75 or older.
The trends of population growth and aging in Russia have been profoundly affected by catastrophic events, such as the two world wars, the civil war of 1917-1922, and famines in the early 1920s and '30s. These catastrophes have distorted the population pyramid--the typical age distribution and balance between male and female in the population. For example, huge losses during World War II have caused Russia to have the lowest overall male-to-female ratio in the world, especially among the elderly. The irregularities of this pyramid will continue to have an impact on the number of births and the rate of population growth and aging for several decades. This pattern affects such vital spheres as school enrollment, employment, and retirement.
Another determinant of the current age structure in Russia has been the declining fertility rate, which is reducing the number of young people in the population. In the past, the prevailing age structure compensated for the long-term trend toward lower fertility. The average age of the population was relatively young, and many women were of childbearing age. Beginning in the 1990s, however, this is no longer the case. The age structure is now such that it will promote a population decrease rather than an increase. Continued low fertility will only accelerate this effect.
The Epidemiological Situation: Deteriorating Russian Health
Perhaps the only genuine crisis aspect of current Russian demographic trends appears in increased rates of mortality, which have been especially dramatic among working-age men. In 1992, there was a sharp increase in deaths from nonnatural causes. By 1994, mortality rates for males between ages 15 and 64 were about twice as high as they had been in 1986. Rising alcoholism and related conditions have figured prominently in this trend. In the mid-1980s, an anti-alcohol campaign championed by Mikhail Gorbachev was responsible for a brief reversal in the mortality trend, but the increase resumed after the campaign was abandoned in the late 1980s.Growing alcohol consumption is not the only explanation of increased mortality. Deaths from violence, injuries, and other nonnatural causes have contributed heavily to the latest rise. Russia's rates of homicide and suicide are among the highest in the world. In addition, deaths from illness and chronic and degenerative diseases, such as cancer, respiratory failure, and circulatory and cardiovascular diseases, have increased sharply. It is interesting to note that environmental problems, generally given a large share of blame for Russia's health woes, are in fact not among the main culprits. Environmental problems cannot explain the increases in accidents, homicides, and suicides or the much greater increases in mortality for working-age males compared with other population subgroups.
Mirroring the increase in mortality rates, life expectancy in Russia has dropped. However, like the fertility trend, the current pattern is not new. In the mid-1960s, after decades of increase, life expectancy began to decline. This trend was reversed briefly in the mid-1980s due, many believe, to the success of the anti-alcohol campaign between 1985 and 1987. However, by 1993, life expectancy fell again. Russia now has the lowest life expectancy for males in a developed country (58 years) and the largest disparity in the world between male and female life expectancy (13.5 years).
The Failing Health-Care System
The increase in deaths from preventable causes points to problems in Russia's health-care system. Again, these problems are not a recent phenomenon. They have accumulated over many years. One characteristic of the Soviet period was a lack of incentives to improve medical services. When changes in the health of the population occurred--such as a decrease of infectious disease and a rise in "civilized" ills, such as alcoholism, smoking, traffic accidents, and pollution, in the mid-1960s--the health-care system failed to adapt appropriately. Excessive reliance on ideology led to ineffectual goals and an emphasis on activities that addressed neither the medical problems at hand, the level of national development, existing medical capabilities, nor public demand. In the 1980s, the system finally made attempts to cope with the changing health environment, but the strategy was poorly implemented and lacked necessary investments in facilities and equipment.
Although these problems were not created by the current socioeconomic crisis, they have been aggravated by the breakdown of the old social system. In the Soviet era, virtually all health care was provided free by the state, whose system emphasized the quantity of medical personnel and facilities, overlooking the quality of services, and pursued goals set on the basis of political ambitions rather than on objective medical needs and economic capabilities.
As the command economy crumbled, the public-health sector plunged into a financial crisis. The system found itself in an emerging market environment without the capacity to function successfully in it. Left without proper funding, health-care facilities were forced to abandon new construction, renovation, and other basic investments. Cost cutting necessitated switching to cheaper technologies, which proved insufficient to maintain needed levels of care. Available funds were frequently diverted to current needs. As a result, the health status of the Russian population is deteriorating, and diseases long thought to be eliminated or controlled--such as diphtheria--are now spreading again.
Reviving an effective health-care system in its current form presents a near-impossible task. Many important medical research centers, especially at the federal level, have been left without proper financial support. Progress in all spheres of health care is under great stress. Faced with this situation, the Russian government has attempted to reform the health-care sector through privatization, marketing services in state-owned facilities, and promoting the private medical sector. One of the main goals of reform is to establish compulsory health insurance financed through taxes and operated by both the state and the private sector. However, the reform has yet to produce noticeable results. Russians are used to receiving free health care and many are unwilling and frequently unable to pay for health services.In addition, serious health-care problems exist that extra spending alone will not address. There are no clearly defined federal and local health-protection policies, no effective programs for monitoring outcomes, and no openly declared systems of control and delegation of responsibilities for state and public health institutions. Moreover, the incidence of destructive behaviors, such as violence and alcohol consumption, has increased. Heavy tobacco use contributes to a high rate of mortality from lung cancer, which occurs 60 percent more frequently in Russia than in the United States. Without attention to these problems, additional funding for health care per se is likely to have little effect.
Looking Toward the Future: Policy Outlook
The current economic crisis significantly limits the Russian government's ability to deal with demographic trends through policy intervention. In particular, the problems of the elderly will be difficult to manage. The retired population is growing, while the financial resources the state devotes to the elderly dwindle. With the declining real value of pensions and the rising costs of health care, the elderly are among the most economically disadvantaged and vulnerable social groups in Russia. The problems that appear most amenable to policy intervention are those related to the health-care system. Thoroughly crafted health-care reform components are essential; an ill-designed benefit package, hasty decentralization, and overreliance on the private sector will only aggravate the situation. At the same time, promoting healthier lifestyles among Russians--reduced smoking and alcohol consumption, better diets--could improve health substantially.