In this paper we discuss the Russian adult health crisis and its implications. Although some hope that economic growth will trigger improvements in health, we argue that a scenario is more likely in which the unfavorable health status would become a barrier to economic growth. We also show that ill health is negatively affecting the economic well-being of individuals and households. We provide suggestions on interventions to improve health conditions in the Russian Federation, and we show that if health improvements are achieved, this will result in substantial economic gains in the future.
Russia remains in the grip of a mortality crisis in which alcohol plays a central role. In 2007, male life expectancy at birth was 61 years, while for females it was 74 years. Alcohol is implicated particularly in deaths among working-age men.
To review the current state of knowledge about the contribution of alcohol to the continuing very high mortality seen among Russian adults
Conservative estimates attribute 31-43% of deaths among working-age men to alcohol. This latter estimate would imply a minimum of 170 000 excess deaths due to hazardous alcohol consumption in Russia per year. Men drink appreciably more than women in Russia. Hazardous drinking is most prevalent among people with low levels of education and those who are economically disadvantaged, partly because some of the available sources of ethanol are very cheap and easy to obtain. The best estimates available suggest that per capita consumption among adults is 15-18 litres of pure ethanol per year. However, reliable estimation of the total volume of alcohol consumed per capita in Russia is very difficult because of the diversity of sources of ethanol that are available, for many of which data do not exist. These include both illegal spirits, as well as legal non-beverage alcohols (such as medicinal tinctures). In 2006 regulations were introduced aimed at reducing the production and sale of non-beverage alcohols that are commonly drunk. These appear to have been only partially successful.
There is convincing evidence that alcohol plays an important role in explaining high mortality in Russia, in particular among working age men. However, there remain important uncertainties about the precise scale of the problem and about the health effects of the distinctive pattern of alcohol consumption that is prevalent in Russia today. While there is a need for further research, enough is known to justify the development of a comprehensive inter-sectoral alcohol control strategy. The recent fall in life expectancy in Russia should give a renewed urgency to attempts to move the policy agenda forward.
To investigate the association between patterns of alcohol consumption and self-reported physical and mental health in a population with a high prevalence of hazardous drinking.
Cross-sectional study of an age-stratified random sample of a population register. SETTING : The city of Izhevsk, The Russian Federation, 2008-09.
A total of 1031 men aged 25-60 years (68% response rate). MEASUREMENTS : Self-reported health was evaluated with the SF12 physical (PCS) and mental (MCS) component summaries. Measures of hazardous drinking (based on frequency of adverse effects of alcohol intake including hangover, excessive drunkenness and extended episodes of intoxication lasting 2 or more days) were used in addition to frequency of alcohol consumption and total volume of beverage ethanol per year. Information on smoking and socio-demographic factors were obtained. FINDINGS : Compared with abstainers, those drinking 10-19?litres of beverage ethanol per year had a PCS score 2.66 [95% confidence interval (CI)?=?0.76; 4.56] higher. Hazardous beverage drinking was associated with a lower PCS score [mean diff: -2.95 (95% CI?=?-5.28; -0.62)] and even more strongly with a lower MCS score [mean diff: -4.29 (95% CI?=?-6.87; -1.70)] compared to non-hazardous drinkers, with frequent non-beverage alcohol drinking being associated with a particularly low MCS score [-7.23 (95% CI?=?-11.16; -3.29)]. Adjustment for smoking and socio-demographic factors attenuated these associations slightly, but the same patterns persisted. Adjustment for employment status attenuated the associations with PCS considerably. CONCLUSION : Among working-aged male adults in Russia, hazardous patterns of alcohol drinking are associated with poorer self-reported physical health, and even more strongly with poorer self-reported mental health. Physical health appears to be lower in those reporting complete abstinence from alcohol compared with those drinking 10-19?litres per year.
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Cites: Bull World Health Organ. 2005 Nov;83(11):812-916302037
There is a consensus that the large fluctuations in mortality seen in Russia in the past two decades can be attributed to trends in alcohol consumption. However, the precise mechanisms linking alcohol to mortality from circulatory disease remain unclear. It has recently been argued that a substantial number of such deaths currently ascribed to cardiovascular disorders are misclassified cases of acute alcohol poisoning.
Analysis of routine mortality data and of a case-control study of mortality among working-age (25-54 years) men occurring in the Russian city of Izhevsk, west of the Ural mountains, 2003-05. Interviews were carried out with proxy informants for both the dead cases (N?=?1750) and the controls (N?=?1750) selected at random from a population register. Mortality was analysed according to indicators of alcohol problems.
Hazardous drinking was associated with an increased risk of death from circulatory diseases as a whole [odds ratio (OR)?=?4.14, 95% confidence interval (CI) 3.23, 5.31] adjusted for age, smoking and education. The association with alcoholic cardiomyopathy was particularly strong (OR?=?15.7, 95% CI 9.5, 25.9). Although there was no association with deaths from myocardial infarction (MI; OR?=?1.17, 95% CI 0.59, 2.32), there was a strong association with the aggregate of all other ischaemic heart disease (IHD; OR?=?4.04, 95% CI 2.79, 5.84). Stronger associations for each of these causes (other than MI) were seen with whether or not the man had drunk very heavily in the previous week. However, associations also remained when analyses were restricted to subjects with no evidence of recent heavy drinking, suggesting that misclassification of acute alcohol poisonings is unlikely to explain these overall associations.
Taken as a whole, the available evidence suggests that the positive association of alcohol with increased cardiovascular disease mortality may be best explained as being the result of a combination of chronic and acute alcohol consumption resulting in alcohol-related cardiac disorders, especially cardiomyopathy, rather than being due to misclassification of acute alcohol poisoning. Further work is required to understand the mechanisms underlying the link between heavy alcohol consumption and deaths classified as being due to IHD (other than MI).
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Male life expectancy in the Russian Federation, at 60 years, is the lowest in Europe. Several factors contribute to this situation, but hazardous consumption of alcohol is especially a key factor.
We undertook a stakeholder analysis in a typical Russian region located on the western side of the Urals. Organizations with a stake in alcohol policy in the region were identified by snowball sampling and information on their position and influence on alcohol policy was elicited from interviews with key informants. Their interests and influence were mapped and their relationships plotted.
Twenty-nine stakeholder organizations were identified and 43 interviews were conducted with their staff. The most influential actors were the Federal and regional governments, large beer producers and manufacturers of strong alcohols. However, the majority of organizations that might be expected to play a role in developing or implementing alcohol control policies were almost entirely disengaged and fragmented. No evidence was found of an existing or emerging multi-sectoral coalition for developing alcohol policy to improve health. Organizations that might be expected to contribute to tackling hazardous drinking had little understanding of what might be effective.
While stakeholders with an interest in maintaining or increasing alcohol consumption are engaged and influential, those who might seek to reduce it either take a very narrow perspective or are disengaged from the policy agenda. There is a need to mobilize actors who might contribute to effective policies while challenging those who can block them.
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Cites: Health Policy Plan. 2000 Sep;15(3):239-4611012397
Cites: Lancet. 2001 Mar 24;357(9260):917-2111289348
Centre for Health Management, Tanaka Business School, Imperial College London, South Kensington Campus, London SW7 2AZ, England, UK. r.atun@imperial.ac.uk
To develop a methodology and an instrument that allow the simultaneous rapid and systematic examination of the broad public health context, the health care systems, and the features of disease-specific programmes.
Drawing on methodologies used for rapid situational assessments of vertical programmes for tackling communicable disease, we analysed programmes for the control human of immunodeficiency virus (HIV) and their health systems context in three regions in the Russian Federation. The analysis was conducted in three phases: first, analysis of published literature, documents and routine data from the regions; second, interviews with key informants, and third, further data collection and analysis. Synthesis of findings through exploration of emergent themes, with iteration, resulted in the identification of the key systems issues that influenced programme delivery.
We observed a complex political economy within which efforts to control HIV sit, an intricate legal environment, and a high degree of decentralization of financing and operational responsibility. Although each region displays some commonalities arising from the Soviet traditions of public health control, there are considerable variations in the epidemiological trajectories, cultural responses, the political environment, financing, organization and service delivery, and the extent of multisectoral work in response to HIV epidemics.
Within a centralized, post-Soviet health system, centrally directed measures to enhance HIV control may have varying degrees of impact at the regional level. Although the central tenets of effective vertical HIV programmes may be present, local imperatives substantially influence their interpretation, operationalization and effectiveness. Systematic analysis of the context within which vertical programmes are embedded is necessary to enhance understanding of how the relevant policies are prioritized and translated to action.
An analysis of trends and determinants of health insurance and healthcare utilisation in the Russian population between 2000 and 2004: the 'inverse care law' in action.
The break-up of the USSR brought considerable disruption to health services in Russia. The uptake of compulsory health insurance rose rapidly after its introduction in 1993. However, by 2000 coverage was still incomplete, especially amongst the disadvantaged. By this time, however, the state health service had become more stable, and the private sector was growing. This paper describes subsequent trends and determinants of healthcare insurance coverage in Russia, and its relationship with health service utilisation, as well as the role of the private sector.
Data were from the Russia Longitudinal Monitoring Survey, an annual household panel survey (2000-4) from 38 centres across the Russian Federation. Annual trends in insurance coverage were measured (2000-4). Cross-sectional multivariate analyses of the determinants of health insurance and its relationship with health care utilisation were performed in working-age people (18-59 years) using 2004 data.
Between 2000 and 2004, coverage by the compulsory insurance scheme increased from 88% to 94% of adults; however 10% of working-age men remained uninsured. Compulsory health insurance coverage was lower amongst the poor, unemployed, unhealthy and people outside the main cities. The uninsured were less likely to seek medical help for new health problems. 3% of respondents had supplementary (private) insurance, and rising utilisation of private healthcare was greatest amongst the more educated and wealthy.
Despite high population insurance coverage, a multiply disadvantaged uninsured minority remains, with low utilisation of health services. Universal insurance could therefore increase access, and potentially contribute to reducing avoidable healthcare-related mortality. Meanwhile, the socioeconomically advantaged are turning increasingly to a growing private sector.
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Cites: Health Care Women Int. 1999 May-Jun;20(3):291-30210633626
Cites: Lancet. 2009 Jan 31;373(9661):399-40719150132
Cites: Health Policy. 2002 Dec;62(3):243-7312385850
Availability and affordability of cardiovascular disease medicines and their effect on use in high-income, middle-income, and low-income countries: an analysis of the PURE study data.
WHO has targeted that medicines to prevent recurrent cardiovascular disease be available in 80% of communities and used by 50% of eligible individuals by 2025. We have previously reported that use of these medicines is very low, but now aim to assess how such low use relates to their lack of availability or poor affordability.
We analysed information about availability and costs of cardiovascular disease medicines (aspirin, ß blockers, angiotensin-converting enzyme inhibitors, and statins) in pharmacies gathered from 596 communities in 18 countries participating in the Prospective Urban Rural Epidemiology (PURE) study. Medicines were considered available if present at the pharmacy when surveyed, and affordable if their combined cost was less than 20% of household capacity-to-pay. We compared results from high-income, upper middle-income, lower middle-income, and low-income countries. Data from India were presented separately given its large, generic pharmaceutical industry.
Communities were recruited between Jan 1, 2003, and Dec 31, 2013. All four cardiovascular disease medicines were available in 61 (95%) of 64 urban and 27 (90%) of 30 rural communities in high-income countries, 53 (80%) of 66 urban and 43 (73%) of 59 rural communities in upper middle-income countries, 69 (62%) of 111 urban and 42 (37%) of 114 rural communities in lower middle-income countries, eight (25%) of 32 urban and one (3%) of 30 rural communities in low-income countries (excluding India), and 34 (89%) of 38 urban and 42 (81%) of 52 rural communities in India. The four cardiovascular disease medicines were potentially unaffordable for 0·14% of households in high-income countries (14 of 9934 households), 25% of upper middle-income countries (6299 of 24,776), 33% of lower middle-income countries (13,253 of 40,023), 60% of low-income countries (excluding India; 1976 of 3312), and 59% households in India (9939 of 16,874). In low-income and middle-income countries, patients with previous cardiovascular disease were less likely to use all four medicines if fewer than four were available (odds ratio [OR] 0·16, 95% CI 0·04-0·57). In communities in which all four medicines were available, patients were less likely to use medicines if the household potentially could not afford them (0·16, 0·04-0·55).
Secondary prevention medicines are unavailable and unaffordable for a large proportion of communities and households in upper middle-income, lower middle-income, and low-income countries, which have very low use of these medicines. Improvements to the availability and affordability of key medicines is likely to enhance their use and help towards achieving WHO's targets of 50% use of key medicines by 2025.
Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
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Comment In: Lancet. 2016 Jan 2;387(10013):9-1126498705
It is known that a range of nonbeverage alcohols including eau-de-colognes and medicinal tinctures are consumed by sections of the Russian population. Research conducted in a city in the Urals (2003 to 2005) showed that consumption of such products is associated with very high mortality from a wide range of causes. However, there have been no systematic attempts to investigate the extent to which such products are available in other cities of the Russian Federation. There is particular interest in establishing this following the introduction of new federal regulations in January 2006 aimed at restricting the availability of these products.
In the first half of 2007, we conducted a survey in 17 cities that spanned the full range of city types in the Russian Federation excluding those in the Far East. In each city, fieldworkers visited pharmacies and other types of retail outlets and purchased samples of nonbeverage alcohols. These were defined as being typically 10 to 15 roubles per bottle, with an ethanol concentration of at least 60% by volume.
We were able to purchase samples of nonbeverage alcohols in each of the 17 cities we investigated. The majority of the 271 products included were a cheaper and more affordable source of ethanol than standard Russian vodka. Medicinal tinctures, sold almost exclusively in pharmacies, were particularly common with an average concentration of 78% ethanol by volume. Most importantly, the majority of the products were of a sort that our previous research in 2004 to 2005 had established were drunk by working-age men.
While the 2006 federal regulations introduced in part to reduce the availability and consumption of nonbeverage alcohols may have had some effect on certain classes of nonmedicinal products, up until June 2007 at least, medicinal tinctures as well as some other nonbeverage alcohols that are consumed appear to have been readily available.
