Medical System Struggles to Overcome Past

MTDr. Alexander Buffonov examining a patient at his clinic in Staraya Sitnya. The doctor tends to more than 2,000 people in 18 villages in the Moscow region.
Editor's note: This is the first of four stories.

STARAYA SITNYA, Moscow Region -- When the call came in for Dr. Alexander Buffonov, the woman was in a panic. She was in great pain and unable to get to a hospital, and she was going into labor. This was her first baby.

Buffonov's first instinct was to grab his stethoscope and hightail it to the woman's house, several kilometers away.

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But the doctor was in a jam. His tiny clinic in this town 120 kilometers south of Moscow had no ambulance of its own.

So he had to wait until a borrowed ambulance from nearby Stupino showed up at 2 p.m., when Buffonov normally made his daily house calls.

Once the ambulance arrived, Buffonov set off for the woman's house. But he faced some roadblocks on the way: the railway crossing that kept him waiting for 40 minutes, and the muddy road the ambulance got stuck in until his driver found a tractor to tow them to drier ground.

"This crossing is really unpredictable," Buffonov said. "You never know when they're going to close it."

As he waited for the green light, Buffonov, 53, smoked relentlessly, fidgeting, wondering what might happen to the woman if he didn't reach her soon. She kept calling him on his cell phone, begging him to hurry up. All he could do was tell her he was coming.

That was three years ago. Today, Russian medicine is supposedly undergoing a top-down transformation, President Vladimir Putin having launched in September 2005 his multibillion-dollar national health care project, the costliest of the four national projects.

One of the top goals of the health care project has been to make sure routine medical emergencies -- asthma attacks, cardiac arrest, broken bones, baby deliveries -- don't turn into tragedies that would likely have been averted in Western countries.

"People are dying because there is no ultrasound equipment, and a simple blood clot is often lethal just because no one found it and prescribed the correct medication," Economic Development and Trade Minister German Gref said last year, shortly after Putin announced the health care project.

Gref's remarks appear to have been buttressed by the World Health Organization, which ranks the health of Russia's population 127 out of 192 member states. The overall state of Russia's public health system is ranked 130th.

When it comes to how much the government spends per capita on health care, the country comes in at No. 75. The WHO said that in 2003, the state spent $167 on health care for every Russian. The United States spent $5,711 per capita; Germany, $3,204; and France, $2,981.

A Great Leap Forward?

For a doctor like Alexander Buffonov, who tends to more than 2,000 patients in 18 villages in the Moscow region, making the leap from rural clinic to modern medical facility will require higher salaries for him and his staff, better equipment and, of course, an ambulance at his disposal 24 hours a day.

On the surface, Putin's plan looks tailor-made for the clinic in Staraya Sitnya.

It focuses on upgrading the nation's primary health care sector, which includes the doctors, nurses, paramedics and hospital aides in Moscow, provincial cities and rural hamlets from Kaliningrad to the Far East, whose job it is to tend to day-to-day crises.

According to the plan, general practitioners and nurses are to get much-needed pay raises, clinics are to be equipped with state-of-the-art diagnostic equipment, and preventive care -- including regular checkups -- is to be a priority.

Figures provided by the office of First Deputy Prime Minister Dmitry Medvedev, who is overseeing the four national projects, show Moscow spending nearly $5.7 billion on health care in 2006, including the national health care project funds.

The project's funds will help pay for $950 million in salary raises, $545 million in new equipment, $132 million in ambulances for rural clinics, $160 million on a nationwide vaccine campaign, $118 million for battling HIV/AIDS, and $1.4 billion for four high-tech medical centers in regional cities.

Next year, money allocated for the health care project is slated to jump to more than $4 billion from $2.2 billion in 2006.

Despite all this, for Buffonov and many other doctors, the plan has yet to bear much fruit.

While Health and Social Development Minister Mikhail Zurabov said in October that the last 900 of 6,700 ambulances would soon be provided to rural clinics, Buffonov has yet to get one; he added that he had received no word that an ambulance is coming. Also, Buffonov still has no cardio-monitoring machine, critically important in a country with high rates of heart disease due to high-fat diets, smoking and alcohol.

Zhanna Odintsova, a spokeswoman for Medvedev, declined to comment, referring all questions to the Health and Social Development Ministry.

A ministry spokeswoman said weeks ago she would need 10 days to provide information but has yet to do so.

On top of all this, there's the question of salaries. Buffonov received an 11,500-ruble raise, jumping to 17,500 rubles from 6,000 rubles per month. One of his surgical aides also got a 5,000-ruble raise. But his remaining 10 staffers are still working for 6,000 rubles monthly.

Morale at the clinic has taken a hit. "I was shocked and offended when I learned that I qualified for nothing, as if I were some second-rate nobody even though the health sector is supposed to be getting a lot of money under the national project," said paramedic Olga Kolodina, who has worked with Buffonov for 24 years.

"In most countries, doctors belong to the nation's elite, but this just isn't the way things work in our country," Kolodina said over a cup of tea, shortly before setting out for a round of house calls.

Kolodina was echoed by doctors in Moscow who also have yet to see any benefits, medical or material, under the national health care project.

"How am I supposed to feel when some of my colleagues received a 10,000-ruble hike, and I didn't get anything, working basically for free?" said Dr. Yelena Kuznetsova, a gynecologist in the southwestern part of the city who estimates she sees from 20 to 35 patients daily.

Sergei Shishkin, a public health analyst with the Independent Social Policy Institute, said distributing pay raises unevenly among doctors and nurses could have troubling consequences.

Tension between general practitioners who receive raises and specialists who do not will inevitably spawn interoffice tension, bribe-taking among specialists will rise and the general workplace atmosphere and, possibly, the quality of medicine will be jeopardized, Shishkin said.

Making Up for Lost Time

What is taking place now, doctors and health care analysts say, is an attempt to make up for years of neglect following the 1991 Soviet collapse.

In the past 15 years, disease and death have skyrocketed while the money for combating them has steadily waned.

One of the most serious problems facing policymakers as they seek to improve the nation's health care system is that things have been so bad for so long that ongoing improvements look less like improvements than basic, long-overdue measures that should have been taken in the 1990s.

Doctors, for instance, who have been underpaid for more than a decade, take the new crop of pay raises for granted, said Kirill Danishevsky, a health researcher at the Open Health Institute of the Russian Academy of Sciences.

As a result, Danishevsky said, the improved pay has done little to boost morale or give health care workers more incentive to work harder.

"Most doctors believe they get miserable salaries for all the hours they spend in their offices treating patients, so they do the absolute minimum in terms of treatment," Danishevsky said. What these doctors don't understand, he said, is that they have it better than front-line physicians, or general practitioners, like Buffonov.

"The GPs have more responsibilities today than doctors trained during the Soviet era," Danishevsky said.

Buffonov said he underwent additional training last year to become an official general practitioner, or GP. But, he added, he has been doing GP work for years -- delivering babies, performing minor surgeries and tending to victims of car accidents.

Compounding the challenge faced by officials trying to revamp the nation's health care system is a culture of disregard for personal well-being.

Kuznetsova, the Moscow gynecologist, noted: "The biggest problem with the women I see in my office is usually they only pay attention to their health when something goes wrong. Few of them would come for regular medical checkups."

Government officials in Moscow say the national health care project is just what the country needs and suffers only from a lack of organization in the regions.

Tatyana Yakovleva, head of the Duma's Public Health Committee and a member of the pro-Kremlin United Russia faction, said she had toured at least a dozen regions in recent months. What she found, Yakovleva said, was that in many regions, clinics didn't know what to do with the equipment bought for them.

"Some clinics couldn't make room at their premises for X-ray machines," she said.

Worse yet, Yakovleva said, some regions stopped spending money on health care once Moscow started spending more, preserving salaries while cutting services. "The president meant joint financing by the government and the regions," she said.

Still, she said, of all the four national projects, health care is the only one that is delivering obvious benefits.

Russians, meanwhile, remain far more ambivalent about the project.

A poll of 1,600 respondents in 46 regions conducted by the independent Levada Center in September showed that 43 percent of respondents thought the national health care project would have a positive effort, and 43 percent thought it would not.

The poll also found that 47 percent of respondents believed the funds allocated for the project would be used inefficiently, 30 percent believed they would be stolen, and 13 percent believed they would be used properly.

The Joy of Healing

Buffonov is understanding of patients with gripes about the health care system. "I know that people in general like to complain about doctors and medicine," he said. "I have no problems with that. Everyone knows me here, and, I believe, respects me."

He added that there had been a few extra rubles for renovating his clinic. But, he said, this money didn't come from any government program.

"I managed to establish good relations with the administration and get some extra money," Buffonov said. He hasn't paid much attention to where the money came from or how he got it.

"It doesn't really matter whether the funds came from the president or the regional district administration as long as we get them," he said.

Ongoing troubles notwithstanding, Buffonov says he expects that the worst is behind him and other doctors.

"For 15 years, I had to combine my usual work with night shifts at the hospital in Stupino to make ends meet," said Buffonov, who has been practicing medicine for nearly three decades. "Thank God I don't have to do that anymore."

But he has concerns about the nation's newest generation of doctors.

"I never did anything else in my life, and I never once thought about quitting my job, but I understand all this can be discouraging for young doctors," Buffonov said.

He hopes the deep satisfaction, even joy, that comes from restoring people to health will help counter frustrations with the system.

He remembers that day, three years ago, when he had to march almost four kilometers to his pregnant patient while a tractor pulled his ambulance out of the mud. Galina, he said, was 21 at the time, scared, uncertain if she would survive, let alone give birth to a healthy baby.

Buffonov arrived just in time. Shortly after the delivery, he was asked to be the baby boy's godfather.

"I've had many similar requests," he said, "many more than I can possibly remember."