In the eyes of many healthcare workers, the war is yet another stage in the disastrous reform known as the policy of “optimization.”
Mobilization and a new wave of austerity might provoke the mass exodus of healthcare professionals from medicine and from Russia altogether.
System Bled Dry
For a decade, the authorities have consistently closed “inefficient” (that is, too costly) health care facilities, mostly related to primary health care: outpatient clinics and day-care facilities, local medical stations, and so on. The countryside was particularly hard hit, as, unlike in urban areas, protests by local residents were not widespread and were barely covered by the federal media.
As a consequence, during the 2010s, about a thousand hospitals were shut down in Russia, and their total number was equal to that of 1932. In 2017, there were half as many hospital beds in the country as in 1990.
In exchange, the authorities promised to increase funding for large modernized clinics and end the deplorable financial situation of medical workers.
In 2012, Vladimir Putin’s infamous May Decrees guaranteed to increase the regional average of doctor’s salaries by a factor of three, while doubling the salaries of nurses, paramedics, and others.
However, social populism turned into the usual bureaucratic eyewash. Since medical institutions received no money to carry out the decrees, the pursuit of an “on-the-books” salary increase resulted in creeping layoffs and the overexploitation of medical workers.
The situation of middle and junior medical personnel — nurses, paramedics, hospital attendants, and others — was even worse. In some places they were simply “eliminated as a class.”
“The May Decrees staged a ‘genocide’ of middle and junior medical staff [Note. Between 2013 and 2019, the number of middle staff fell by 128,000 people, from 1.44 to 1.31 million, and of the junior staff — by 421,000, from 687 to 266 thousand]. In some hospitals there are no nurses at all, and nurses are listed as cleaners,” said Dmitry (name changed), a trade union activist in the healthcare system who asked to remain anonymous.
The number of doctors was also in decline, although at a slower pace. In 2013, the country had 579,000 doctors (41 per 10,000 population), while in 2019 their number is estimated to have fallen to 565,000 (38.5 per 10,000). For this reason, at the early stages of the implementation of the optimization policy, experts sounded the alarm about the lack of specialists, which in some regions reached up to 50%.
Ten years after the May Decrees, healthcare is suffering from the same diseases as before the decrees, often in an even more severe form.
In 2021, 90% of doctors surveyed by the professional network Vrachi.rf (Doctors.rf) complained about staff shortages, and almost half attributed the shortages to low salaries.
Contrary to official statistics reporting an average medical doctor’s salary to be one hundred thousand rubles a month (and this is a case in point), the actual income of doctors is usually several times lower.
Almost 40% of doctors earn no more than 40,000 rubles a month (a negligible amount, equivalent to the salary of a cashier), while the average monthly wage is 30,000 rubles, and the value of the salary (constant part of the salary, minus bonuses, etc.) — 20,000, according to the estimation of the All-Russian Union of patients based on a survey of 1,500 surgeons and physicians in 58 regions.
It comes as no surprise then that at the turn of the decade healthcare workers have become one of the most combative professional communities. In 2019 and especially in 2020, healthcare has far surpassed other sectors of the economy in the number of labor conflicts.
Since medical workers are forbidden to strike, they often resorted to work-to-rule job actions (when pedantic compliance with instructions stalls work) and joined free unions that are not part of the official trade union center of the FNPR (Federation of Independent Trade Unions of Russia): the Action (Deystviye) and the Alliance of Doctors (Alyans Vrachey).
Putin Promises Equality
Faced with growing discontent, the authorities, through Vladimir Putin, acknowledged the “excesses” committed in the course of optimization and implementation of the May Decrees. Shortly before the pandemic, healthcare workers were promised the restoration of primary healthcare in the provinces and the development of “fair and understandable” rules of remuneration.
The Industry System of Labor compensation (OSOT), drafted by the Cabinet on Putin’s instructions, provided all medical personnel with a unified list of allowances, bonuses, and compensation (which often account for the major share of their income) and a fixed proportion of these payments to their salaries.
The reform was expected to be tested in several pilot regions in the summer of 2021, and by the end of this year it was supposed to be implemented throughout the whole country.
The unions saw the initiative as a victory, because the authorities seemed to be meeting their demands, promising to reduce the wage disparity between physicians with the same qualifications working in different hospitals and regions, and thus to saturate understaffed medical institutions with personnel.
However, the Covid pandemic and then the war put an end to these hopes.
The Corona crisis as a Moment of Truth
The pandemic clearly demonstrated the pernicious effects of years of healthcare austerity policies.
“The crisis undermines what has been undermined and exacerbates what has been exacerbated already. The Corona crisis revealed huge problems within the healthcare system that have not been solved previously and are not being solved now: the shortage of personnel, their low level of organization and qualifications, the absolute incompetence of management,” says Nikolay (name changed), an anesthesiologist at a St. Petersburg hospital.
According to the medical doctor, by the beginning of the pandemic, few hospitals had normal zoning (dividing the facilities into “clean” and potentially infected areas). Medical workers were desperately short of special suits and other means of protection. This resulted in a high mortality rate among doctors and nurses, which according to an unofficial accounting exceeded fifteen hundred.
The staff shortage, intensified by the optimization, had ominous consequences for patients. According to some testimonies, at the peak of morbidity doctors were forced to resort to so-called medical triage, that is, to decide which of the patients to assist (with the greatest chance of success), and which to condemn to death.
In addition, the mobilization of scarce healthcare resources to combat Covid, to the detriment of other areas of care, spurred deaths from other diseases, such as diabetes.
The government restrained the outflow of medical personnel from the industry using special social payments to physicians working with Covid patients.
In 2020, doctors were entitled to a monthly allowance of 80,000 rubles, and nurses, paramedics, and ambulance staff — 25,000-50,000 (later payments were calculated based on the number of shifts). In the event of infection or death of a person, the patient or their relatives were paid insurance from 69,000 to 3,000,000 rubles.
“At least we didn’t have to work two jobs to have anything more than food for thought,” explains trade union activist Dmitriy.
Optimization Continues with Different Means
The invasion of Ukraine, which coincided with a drop in coronavirus deaths, put an end to the “covid” payments and the hope that the situation in healthcare would change for the better.
The first signs of a new wave of austerity were evident as early as last fall. “We began to get signals that the regions were tightening the requirements for Covid payments. Many of them started paying only for a confirmed diagnosis (COVID-19), not for a shift…. [Doctors] were threatened that an inspection from the FSS (Social Security Fund) would be conducted and they would have to pay back the money from the hospitals’ funds. As a result, in the first half of 2022 the outflow of personnel from healthcare resumed,” says Dmitry.
In June, the government canceled all Covid support measures for medical workers ahead of schedule. They were replaced with a 25% increase in salary for hazardous working conditions.
Since salaries in healthcare are often below the minimum wage rate, this “substitution” simply means the abolition of guarantees, while the situation with Covid, according to official statements, “remains tense.”
Some groups of physicians received nothing at all.
“For some unknown reason, the paramedic teams in the front line of the fight against Covid were not compensated. It feels like [the authorities] are making people angry on purpose, [provoking labor protests]. After all, paramedics are the most organized part of the medical worker community, accounting for 80% of the union,” says Dmitriy.
Withdrawal of “Covid payments” hit the income of the vast majority of doctors — 70% of doctors surveyed by the journal Medical Herald (Meditsinsky Vestnik), expected a decrease in their salaries by 20-30%, and another 8% — by 50-60%.
Then the OSOT project went into oblivion, taking away the last hopes for a review of the results of optimization.
“The effect of the decree [on the implementation of the pilot project] was suspended until January 1, 2025. In fact, this is the abolition [of the reform]. There is an order from the President, but they are not going to carry it out, obviously hoping that things might change and they won’t need to do anything,” said the trade union activist, sharing his disappointment.
The fact that the war rendered obsolete the results of medical workers’ long struggle for their rights is underscored by the repression of medical unions, which practically deprived them of the opportunity to take collective action.
Last year the authorities designated the Alliance of Doctors as a foreign agent. Its head, Anastasia Vasilyeva, was placed under house arrest in connection with protests in defense of Navalny. Some activists from the Alliance have emigrated.
One of the regional coordinators of Action was jailed for six and a half years on charges of fraud. It is not clear whether the sentence is related to his human rights work or previous commercial activities, but such criminal charges are often a cover for political persecution.
The authorities are cutting not only the salaries of medical personnel, but also the financing of the system as a whole. The 2023-2025 federal budget proposes that the health care system be cut from 372 billion rubles this year to 310 billion next year.
At risk are expensive treatments, including so-called quota surgeries — complex, high-tech procedures such as organ transplants or prosthetic joints, says anesthesiologist Nikolay.
“They started cutting quotas, lowering rates, for example, for aortic valve replacement, femoral neck replacement, arthroscopy…. Because all the money goes to the front, and war is a costly affair,” the doctor believes.
The media reported other similar cases, in particular the attempt to cut funding for chemotherapy at the Pirogov Clinic in St. Petersburg.
Nikolay “dreads” the new year, when the Ministry of Health will distribute quotas to clinics. The salaries of specialists, among other things, depend on them.
“Recently funding has been decreasing constantly. Most [surgeries] were already at the limit of their budget, and now, by all appearances, they will go beyond that. We don’t know how to survive in these conditions,” the doctor fears.
The growing international demand for medical professionals, coupled with Putin’s announced “partial” mobilization, suggests a way out for healthcare workers.
Medical Workers and Mobilization
At first the war hardly affected the medical workforce. Civilian hospitals did not treat the wounded, and disruptions in the supply of imported medicines or medical equipment were no more serious than usual.
February 24 divided healthcare workers, like the rest of Russian society, into a majority that passively approved of the “special operation” and a minority of “super-patriots” and opponents of the war.
“Some people, of course, speak out in favor of the war, especially when they are in no danger. There are a certain number of those who speak out against [the war], but they tend to do so quietly, because they understand how the wind blows. Here, the main employer is the state. Over decades of working in the system, people have realized that they are slaves here,” says the anesthesiologist.
However, according to the doctor, since summer 2022 there have been fewer hurrah-patriotic statements in his circles.
“People can see that something has gone wrong…. No one personally gives a damn about this war. I do not know a single doctor or nurse who would go to the front voluntarily,” says Nikolay, conveying the sentiments of his colleagues.
Rumors coming from military hospitals do not contribute to pro-war sentiments. According to some testimonies, the war mirrors the Corona crisis: the system, weakened by optimizations, proved unprepared for disaster.
“War, just as a trauma epidemic, requires expensive and specialized care. Let’s say a leg injury. A qualified [surgical] team can fight for the leg, but an unqualified surgeon, lacking the necessary equipment, will simply amputate it and leave a person disabled for life.
But the number of highly qualified specialists is limited. Plus, the surgery has to be done quickly, with the right equipment and medications. We lack everything at all stages…. Patients are brought in late, with poorly provided [primary] medical care,” testifies Nikolai.
Mobilization is less frightening for healthcare professionals than, for example, for factory workers who risk going to the trenches straight from the workshop. Despite excesses, such as the cases mentioned by Putin in which mobilized doctors were enlisted in the army as motorized riflemen, normally they end up in base hospitals.
On the other hand, says Nikolay, some people still remember the first Chechen war, when doctors were sent to the front lines. In the chaos of the mobilization, no one can guarantee that it will not happen this time.
The threat hangs over not only men, but also women, who make up 70% of medical stuff.
“Women with high-demand skills receive call-up papers, but so far they are just registered in the reserve,” says Nikolay.
“Women with military backgrounds, especially those who have children, are noticeably nervous. No normative documents [on the order of their mobilization] have been published. Nothing except verbal statements that women will be mobilized in the third wave,” says Dmitry, trade unionist, adding that so far he is not aware of any cases of female medical workers being drafted.
According to the trade union leader, sending medical workers to war has not yet become a mass phenomenon. “The damage [to healthcare] of mobilization has’t so far outdone the one caused by optimization and underfunding,” he believes.
Still, tensions mount. In some places, medical workers are forbidden to take vacations or travel abroad. For example, the St. Petersburg Public Health Department ordered chief physicians to keep their subordinates from traveling abroad. In Tver, doctors were prohibited from taking vacations and declared unable to travel beyond the borders of the region. Against the background of the “partial” martial law declared in Russia on October 20, this may be the first sign of the militarization of the healthcare system.
Few people are impressed by such a prospect. That’s why doctors, like other workers, frantically cling to their exemptions and find other ways not to go into the army.
“We, doctors, are hard to mobilize, because we still have some power to make decisions in this system. For example, to contrive a diagnosis which will prevent us from being conscripted. The only thing that saves someone from mobilization now is category D [which means serious diseases, like tuberculosis, HIV, or schizophrenia]. People obtain this category for themselves, they resort to corruption, nepotism, and connections,” says Nikolay.
Others pack their suitcases and leave the country.
“Many of those I know think about leaving and are taking steps toward emigration. But it’s not an easy thing to do, because the departure of a medical doctor, like any highly qualified person, means having your qualifications recognized and valid. There are countries that recognize our documents — you can go there in no time. Some are in the process of confirming their papers and are about to leave. Others freaked out and left without any preparations to wait out,” says the doctor.
Those who don’t have the means to leave or hide, hope for a deferment. But in healthcare, as in other sectors, distribution of deferments is nontransparent and depends on the arbitrary decisions of the authorities.
Some hospital managers are fighting for every employee, realizing that the loss of even one specialist can be fatal. “If a city hospital has ten district therapists, and one of them is taken away by the special military operation, it will affect the people they treat, because the staff shortage is acute,” Dmitry explains.
Others let things slide, while others again use the exemption to encourage sycophants and to get rid of unwanted people.
“Through the mobilization superiors exercise enormous power. I know people who have been told that they will have deferrals, but they don’t actually know whether it’s true or not. Everything depends on the management; they have been treating employees as slaves before this too. Now it’s a job with a death-sentence ending, because being fired would mean being sent to the front. That’s why they offer petty salaries. No one would dare to say a word,” assures Nikolay.
According to Nikolay, Russian doctors will adapt to the war, just as they have adapted to other crises. But the inevitable deterioration of working conditions and reduced funding will force many of them to leave the profession sooner or later or to emigrate. “No one wants to waste time and money on all this crap,” concludes the doctor.