Letters

It is surprising to see such a misleading article about the Russian health services ('Gone West', features, pages 26-27, 14 October), starting with the implied link between the state of the health services and diseases like AIDS and tuberculosis. Would that the health services were so effective. Perhaps the economy's collapse, the social stress of a country in turmoil and the increase in alcohol and drug use have more to do with it than any change in health services or funding.

Apart from this, the Russian health services have inherited problems, common to much of Russian industry: a grossly underfunded, over-large, overstaffed and inefficient service. Professor Komarov's figures probably understate the situation since the 1998 devaluation. In one of the more prosperous regions, spending on primary and secondary healthcare is now $25 per head per year.

Problems in the health services are not to be denied, nor is the need for change.

The effects of isolation from world thinking have been profound, and the barriers to communication damaging.

The means of spreading new ideas are poorly developed.

The organisational solutions advanced have not been helpful. It is not useful to parody the insurance system, which was based largely on the German model. Those in work contribute via a payroll tax, and the regional administration contributes for the young, the old and the unfit.

The hope was that the payroll tax would increase available funds when other types of tax collection were new and grossly inefficient. Currently, tax revenues are about 15 per cent of the declared and very low GDP. The economic collapse of the mid-1990s made the always optimistic hope of increasing revenue completely vain.

The territorial funds and insurance companies were an inefficient distribution mechanism for essential state funding for health. The intention that they function like the German funds was never realised. Payment by notional cost per case is an inheritance from the old Russian system, not a feature of the insurance system.

It is easy to express horror at the failure to pay staff. Perhaps it should be a sobering reflection that in times of financial crisis Russia cuts payment to staff before it reduces services to patients.

There are many problems and a lot to learn. It is a system desperately trying to overhaul itself while coming to terms with the move from the planned system, which paid little heed to money, to one using normal financial mechanisms. It is doing this when the national economy is in dire straits.

Problems and lessons - yes. Gone west - no.

Martin McNicol London W13