Karina Vartanova,1 Alexander Kulikov,2 Pavel Krotin.3
1UNICEF Russian Federation, Moscow.
2Department of the Medical Academy of Postgraduate Studies, St Petersburg.
3City Consultative and Diagnostic “Juventa” Centre, St Petersburg Executive summary
The Russian Federation faces a demographic crisis, with an average population decrease of 700 000 people per year.
Child and adolescent mortality rates give cause for concern. External causes of mortality dominate in all age groups of children and adolescents, with a sharp increase seen in the 15−19 age group. The mortality rate due to external causes for this group in 2005 (including suicide) was 85.8 per 100 000, with a suicide rate of 19.6 (1). Analysis of adolescent mortality reveals that 75% of all deaths were preventable as they were caused by chronic diseases (20%), substance misuse/poisoning (6%), alcohol poisoning (5%), accidents (34%), suicide (30%) and unknown causes (5%).
Prevention strategies and health promotion interventions are needed to reduce morbidity and mortality and to enable children and young people to develop into healthy, contributing adults. They are also crucial in safeguarding the reproductive health of young people.
While the government has identified young people’s reproductive health as a priority, health care and education systems are not yet properly equipped to address their specific needs. To bridge the gap between the health needs of young people and existing health care services, the Ministry of Health and Social Development of the Russian Federation and the United Nations Children’s Fund (UNICEF) Russian Federation have developed and promoted the concept of integrated youth-friendly health services, a model that provides young people with an easily accessible range of age-appropriate health, social, psychological and information services.
To date, 117 youth-friendly service facilities have been established in 28 Russian Federation regions. They provide reproductive, sexual and mental health services to approximately 1.5 million young people.
A two-pronged strategy is being pursued, through which UNICEF supports field-level efforts to establish youth-friendly health services in line with international standards and adapted to local circumstances, while at the same time investing in the capacity-building of relevant professional communities throughout the Russian Federation.
Youth-friendly health services provide a tried and tested way of promoting better health among young people and their families. With relatively limited funding, effort and time, youth-friendly health services can be made available to young people throughout the country. UNICEF expects that over time, they will contribute to safer and healthier behaviour among adolescents and young people, reducing the dramatic health statistics and mortality rates that underlie the Russian Federation’s demographic crisis.
Background
Economic, sociocultural and demographic context
As of 1 January 2009, the Russian Federation had a population of 141.9 million (2). While ethnic Russians account for about 80% of the total population, over 160 nationalities are also represented.
About 73% of the population is classified as “urban” and live in the country’s 1066 cities and 2270 urban settlements, children and young people aged 0−19 years account for approximately 22% (31 million at 1 January 2008).
The Russian Federation consists of 83 self-governing constituent units (subjects), including 9 territories (krais), 46 regions (oblasts), 21 republics, 2 cities of federal importance, 1 autonomous region (autonomous oblast) and 4 autonomous areas (autonomous okrugs). The cities of Moscow and St Petersburg are
considered constituent units (subjects) in their own right. In addition, the Russian Federation territory is also divided into 7 federal districts for administrative purposes.
The 83 constituent units differ substantially in terms of natural resources, economy and geography. They also tend to be extremely diverse within themselves: for example, regional centres often have a developed labour market and infrastructure, while small towns and rural areas have low income levels, much lower living standards and limited education and recreational facilities, restricting young people’s development opportunities.
The Russian Federation’s economy grew by 7% a year from 1999 to 2007, and this trend continued in the first half of 2008, with an 8% increase. Poverty fell to 14.7% in the first half of 2008 (from 29% in 2000), with approximately 30 million people moving out of poverty between 2000 and 2007. However, the global financial crisis has posed new challenges for the Russian Federation’s macroeconomic and social policies.
Over the last quarter of 2008, the economy experienced a gradual slowdown which resulted in a gross domestic product (GDP) growth of 6% for 2008, compared to 8.1% in 2007.
While substantial financial reserves protected the Russian Federation from feeling the full impact of the crisis in late 2008, a recession started in 2009. This has already led to a budget deficit and the scaling-down of socioeconomic programmes. These conditions have caused losses in real incomes and employment and a rise in poverty. Though there are as yet no reliable data on young people’s unemployment rates, it is presumed that the consequences of the economic crisis will significantly affect job opportunities for this population group.
Tackling the Russian Federation’s demographic crisis continued to be a national policy priority throughout 2008. The child population decreased by 5 million between 2002 and 2007, with the falling trend continuing in 2008 (Fig. 1). Monetary benefits introduced to improve the living standards of families with children and to encourage them to have more children have, however, contributed to sustaining a slow but positive growth in the birth rate: the number of births increased by 8.8% in 2007 and by 6.6% in 2008, but the 2008 birth rate of 12.1 births per 1000 population was still lower than the death rate (14.6 deaths per 1000 population). Consequently, the population decline continued (Fig. 2).
Fig. 1 Population of the Russian Federation, April 2008
Source: Rosstat,8 April 2008
8Rosstat, the State Committee on Statistics of the Russian Federation, is the country’s main statistical agency.
Fig.2 Natural population growth in the Russian Federation (1990−2008) Source: Rosstat, April 2008
The Russian Federation’s child and adolescent mortality rate (0−19 years) is 75.7 per 100 000 children, almost four times higher than that for western European countries (3).
In 2005, mortality due to external causes for 15−19-year-olds was 85.8 per 100 000, with a suicide rate of 19.6 per 100 000. Analysis of adolescent mortality reveals that 75% of all deaths were preventable as they were caused by chronic diseases (20%), substance misuse/poisoning (6%), alcohol poisoning (5%), accidents (34%), suicide (30%) and unknown causes (5%). The major groups of diseases leading to the high mortality rate in this age group are determined by adolescent risky behaviours.
The priority health and development needs of young people
On the whole, families with children face greater risks of poverty, with children’s risk of poverty being almost twice as high as the general population (4). They have faced great economic difficulties and stress over the past 20 years, which has resulted in an increased incidence of family breakdown and greater numbers of children being forced into vulnerable situations. Children’s increased vulnerability is also fed by a high divorce rate. While Rosstat figures show that the divorce rate decreased to 4.2 per 1000 people in 2005, the problem remains traumatic for the children and young people affected.
Substance misuse is another factor that contributes to family breakdown. According to a 2002 study by the Moscow nongovernmental organization (NGO) “No to Alcohol and Narcotics Addiction”, parental alcoholism was the main reason for delinquency in children, comprising 71% of the two-parent families surveyed (5).
Domestic abuse and violence remains a serious problem affecting the life perspectives of children and young people. National statistics on abuse towards children provide some indication of the scale of this problem.
Every year in the Russian Federation, approximately 15 000 minors under 14 years die. Fifty per cent of them die from unnatural causes, with more than 2000 dying as a result of murder or severe physical abuse.
These deaths are frequently the result of failure of parental care and supervision (6).
The current generation of young people are living through an unprecedented period of extraordinary change
and uncertainty and are ill-equipped to deal with the emerging challenges. Risky behaviours, reflected by an increase in the rates of tobacco, alcohol and drug abuse, frequently lead to accidental and violent death, including suicide. The prevalence of alcohol use among 15-year-olds is believed to be 30%, and the rate of cigarette smoking is 33%. Experts estimate that the Russian Federation ranks fourth in the world in terms of tobacco consumption among this age group.
Results from a survey of boys’ attitudes to risky behaviours (7) are shown in Table 1. For girls, risky behaviours frequently result in unwanted pregnancies.
Table 1. Boys’ risky behaviours (7)
In the Russian Federation, as in the rest of the world, young people are disproportionately affected by HIV, with 73% of people living with HIV being diagnosed when they were between the ages of 15 and 30 years.
A total of 54 046 new cases of HIV infection were reported in the Russian Federation during 2008, 20.6% up on the figures for 2007. By the end of the year, the total number of people in the Russian Federation known to be HIV infected reached 470 985, of which 34 865 had died and 436 120 were living with HIV (no age and sex disaggregated data on new cases of HIV are available from published sources).
Unsafe drug use remains the main mode of HIV transmission (63% of infected people are injecting drug users), but heterosexual transmission is growing rapidly (approximately 35% of all cases with established mode of transmission in 2008, versus 20% in 2002). According to the head of the Federal Narcotics Control Service (FSNK), there are 2.5 million addicts and more than 5.1 million drug users in the Russian Federation, almost double the 2002 figure. Heroin and other opiates predominate; the proportion of people in the Russian Federation using opiates is the highest in the world for countries with populations larger than 100 million, and five to eight times greater than the European Union (EU) average.
On 4 July 2009, President Medvedev told a youth forum that drug addiction, along with alcoholism and smoking, represented a serious threat to the Russian Federation’s future. He noted that 40% of the country’s young people smoke and that average per capita alcohol consumption has reached the equivalent of 18 litres of pure alcohol per year − twice the level at which serious medical and genetic damage become apparent.
The FSNK estimates that 10 000 people in the Russian Federation die each year through overdoses and that another 70 000 deaths are drug-related; however, the FSNK head recently suggested that the actual overdose toll may be as high as 30 000.
Deaths from these causes are disproportionate among young men (the average age is 28 years) (8).
Since the early 1990s, the adolescent suicide rate has increased by 28.2% among boys and by 9.2% among girls (9). Experts estimate the level of depression among adolescents in the Russian Federation to be about 20%.
The issue of adolescent pregnancy in the Russian Federation causes concern. Between 2000 and 2004, there was an 11.7% increase in the number of births among girls aged 17 years or younger. That equates to 41 159 births in 2004 compared to 36 831 in 2000 (10). The majority of these births were among 16- and 17-year-olds who face greater medical risks and are likely to be less psychologically prepared to care for a child. Since pregnancy among adolescents is more frequently accompanied by complications, the chances of maternal mortality in this group have grown dramatically.
The situation regarding abortions among adolescent girls also warrants concern (Fig. 3) (11) . Rosstat figures for 2004 (the most recent year for which official data are available) show that the rate of abortions performed for 15−19-year-old girls was 29 per 1000. For those under 15 years, the figure was 0.1 per 1000.
Although the number of abortions among 15- to 19-year-old girls is falling, the rate for those under 15 has risen in recent years. While estimates differ, it seems that around 10% of abortions are performed on girls under 19 years, and about 88% of pregnancies in girls under 15 years end in abortion (6).
Experts from the Russian Federation offer no single explanation for the decrease in the number of abortions, but among the most common reasons cited are a general increase in contraceptive knowledge and underreporting of abortions carried out in commercial medical centres, who very often do not submit accurate data on abortions to state health agencies.
Fig. 3 Number of abortions, age under 20 years (2004) (11)
Health system context and health services available for young people: organization of health care Until recently, the Russian Federation’s health care system was resource-based rather than results-based, which translated into an emphasis on curative rather than preventive responses. The development of public health policies and strategies is progressing slowly and remains a challenge.
The Russian Federation Government’s national project priority of modernization of health care has the potential to significantly improve children’s and young people’s health. The programme focuses on making primary health care more accessible and of better quality. The federal programme “Children of Russia” also has a key component (“Healthy generation”) in its 2007−2010 plan that focuses on health. Objectives for this project include guarantees on safe maternity care and healthy childbirth, protection of children’s and young people’s health, including their reproductive health, and prevention of child and adolescent illnesses, disabilities and deaths.
Until 1999, children were seen at children’s outpatient polyclinics until the age of 15 and were then moved on to adolescent departments of adult clinics. One of the first decisions made by the Ministry of Health as part of reform of the provision of medical services for young people was to keep children at children’s polyclinics until the age of 18. These children’s polyclinics provide free services for the child population living in the catchment area, providing they have valid compulsory medical insurance. Children’s polyclinic doctors (neuropathologists, oculists, ear, nose and throat specialists, urologists, surgeons, children’s and adolescents’ gynaecologists, cardiologists, endocrinologists, etc.) diagnose and treat acute diseases and monitor the health of children with chronic pathologies. Polyclinics also perform laboratory analyses for children, including for HIV infection.
Family medicine is currently provided by family doctor offices that may be located either within adult polyclinics or as separate entities. They are not yet widespread in the country and have proved inefficient in meeting adolescent-specific health needs.
Adolescents tend to be caught between these two elements of the health care system, their needs considered beyond the scope of each. The transfer of 15−18-year-olds to the paediatric network essentially did not alter the situation in relation to adolescent reproductive health. Health care for adolescents is provided by paediatricians in local children’s polyclinics, but their counselling approaches tend to be tailored towards the needs of young children. With an average of 12 to 15 minutes for each patient, doctors are not able to address adolescents’ specific counselling needs. Adolescents who have had long-term relationships with their local paediatricians are often embarrassed to discuss difficult issues such as contraception or sexually transmitted infections (STIs), and may also worry about breaches of confidentiality.
School medicine, as part of primary health care, is supposed to provide (in close cooperation with children’s polyclinics) a range of preventive services for children and adolescents of school age. In reality, however, the overwhelming majority of school medical units have a deficit of medical professionals and, as a rule, are staffed by paramedical personnel who deal mainly with vaccination and monitoring the quality of school food.
Specialized reproductive and sexual health services for adolescents and young people are also provided by a number of state health institutions: dispensaries (dermatovenereological, narcological), maternity clinics (girls’ reproductive health, pregnancy and childbirth), family planning and reproduction centres, and AIDS and infectious disease prevention centres. Despite their offer of free testing, diagnostic and treatment services, these health institutions are not attractive to the majority of adolescents and young people.
Socially vulnerable categories of young people (drug users, commercial sex workers, unsupervised and street children) have the same rights as other groups of the population, but in reality they have very limited access to health services, with the exception of those provided by NGOs.
A question that often arises is whether special services for young people are really necessary when there are medical institutions all over the country that serve both adults and children. The statistics show, however, that the average age for adolescents to become sexually active is decreasing, the numbers of STIs and early pregnancies are increasing, drug abuse, smoking and alcoholism are spreading, young people are becoming involved in the sex industry and the HIV/AIDS epidemic continues. Adolescents are not welcome visitors at regular clinics; they are considered by staff to be unreliable, financially insolvent and “peculiar” in their ways. And young people themselves are not very willing to come to regular medical institutions – they do not want to be treated coldly and with indifference and are wary of confidentiality issues (summary results of UNICEF Russian Federation partner organization surveys, polls, questioning and focus groups with adolescents, unpublished data, 2009).
In general, the health care system as it is today is not equipped to address the specific needs of adolescents and young people in the area of reproductive and sexual health, mental disorders and risky behaviour prevention. Available health services are mainly disease-oriented and there are no comprehensive primary care-level services that address both prevention and treatment. The inability of health services to meet adolescent health needs often results in adolescents failing to seek necessary treatment or counselling and being unwilling to expose themselves to criticism or stigma.
Financing
While private medical institutions exist, the Russian Federation medical system is mostly free and is available to anyone who has the so-called “mandatory medical insurance” (MMI). The system of MMI covers most of the state medical institutions; any citizen of the Russian Federation can receive MMI in the district of his or her permanent residence. At the same time, people can use the services of private medical
insurance companies and medical institutions.
The types and scope of medical care provided free of charge to the population of the Russian Federation (including children and adolescents) are outlined in the “Programme of state guarantees for the provision of free medical care to citizens of the Russian Federation in 2005”. The programme is financed out of budgets at all levels (federal and municipal) and by mandatory medical insurance contributions and other revenues.
Under the programme, children, adolescents and young people can receive the following types of assistance free of charge:
medical assistance provided at specialized medical institutions for , for example, STIs, tuberculosis,
•
AIDS, psychological disorders and behavioural disorders, and drug-related diseases (financed out of the budgets of the constituent entities of the Russian Federation);
STI and unwanted pregnancy prevention, contraceptive help (both counselling and contraceptives),
•
HIV and STI testing at outpatient and inpatient facilities of polyclinics and hospitals (financed out of the budgets of municipalities, primary medical services and sanitary assistance); and
regular preventive health checks for all children and adolescents, including those who are healthy,
•
assistance during pregnancy, birth and the perinatal period, and abortion services (financed out of the basic MMI programme).
The list of health care services covered out of state budgets is wider than the list covered out of MMI: for instance, MMI does not cover services that are crucial in working with adolescents and young people, such as psychological counselling and social support. There are also difficulties in serving the reproductive and sexual health needs of adolescents and young people.
The lack of or shortage of budgets and financing from MMI contributions alone can reduce the scope of services available to adolescents. Free HIV and STI testing is available only within budget financing and is
The lack of or shortage of budgets and financing from MMI contributions alone can reduce the scope of services available to adolescents. Free HIV and STI testing is available only within budget financing and is