Hospital No. 7 is a relatively modern multi-building complex set amid a large swath of green space in south-central Moscow. It's one of the city's busiest general hospitals, taking in about 200 new patients daily.
But under a new reform, imposed with little public notice or explanation by city government, several departments have been shut down, almost half the staff laid-off, and no one is sure what's going to happen next.
"I've been laid off, I just have a few days to go, and still no one has explained anything to me. How will I find a new job?" says Dmitry Volkov, a surgeon who's worked 17 years at Hospital No. 7. "We have so little staff left here, that doctors have to wheel the patients into the operating room by themselves. It's unbelievable."
The official plan to shut down 28 (out of 204) city hospitals and fire up to 10,000 medical personnel, leaked onto the Internet in October, has triggered a wave of public outrage. In the first economically-motivated mass protests in over a decade, thousands of people demonstrated in downtown Moscow last weekend, complaining that the quality of healthcare provided by the mandatory state insurance program is deteriorating, and accessing it is becoming far more difficult.
Good care, they say, is available only through the small but growing private health sector which is unaffordable for most Muscovites. Rumors of corruption are rife, including claims that city officials plan to sell the property of closed hospitals to developers, to become hotels, shopping centers, or even private medical clinics.
Similar protests will be unfolding throughout this month all around Russia, as the country begins to realize a law passed in 2010 that requires all medical costs to be funded by the insurance schemes run by regional governments.
But the plan, which was originally conceived in relatively prosperous times as an effort to cut waste, is now being implemented amid a fast-deteriorating economic conditions that have seen the ruble plunge, inflation spike, and uncertainty spread like wildfire. Nobody is yet suggesting that the relatively small spasms of protest threaten President Vladimir Putin, who still enjoys stratospheric popularity ratings, but few doubt that it's an alarming signal.
"It's a classic situation. Back in 2010 there was a feeling that unpopular decisions might be avoided, that giving it time would ease the problems," says Alexei Makarkin, deputy director of the independent Center for Political Technologies in Moscow. "But now these reforms must necessarily be carried out in an increasingly unfavorable situation, when the population is already feeling alarmed."
Officials responsible for the Moscow reform argue that the reform is mainly aimed at managing available resources. At a press conference last week, Alexei Khripun, the head of Moscow's Health Department, insisted quality and accessibility would actually improve, and that displaced medical personnel would be offered re-training and job placement services by the city.
Artyom Doletsky, a cardiologist and associate professor at Sechenov University, a clean, high-tech teaching hospital in central Moscow, says that the system would benefit from a well thought-out overhaul.
He says that in the past decade Russian authorities threw billions of dollars at the national healthcare system, "but what we have found is that public health showed no improvement. The problems are much deeper than that," he says.
For one thing, he argues, "bed turnover" – the amount of time a patient spends in hospital – is at least three times higher in Russia than in Western countries. "In Europe or the US, someone may spend a day in hospital having some procedure done, then be released and handled on an outpatient basis. Here, the patient will spend up to a week in hospital, taking up the resources," he says.
For another, Western doctors undergo constant educational upgrading. In Russia, doctors need only take refresher courses every five years, Dr. Doletsky says.
"The average level of doctors in this country is mediocre. We need comprehensive reforms to move our system closer to Western standards," he says.
...or all about profit?
Critics say they're not opposed to "optimization," but so far it seems like just a bureaucratic buzzword for slashing services.
"In real life it leads to the deterioration of healthcare, reduction of beds in hospitals, and layoffs of qualified staff," says Alla Frolova, coordinator of the Together for Decent Medicine movement that organized last weekend's Moscow protest. "We have big questions about the course of this so-called reform. For example, what's happening to the property? Two children's hospitals were shut down in Moscow, and two multi-storied hotels appeared in their place."
The most controversial allegation of all is that the reform is just a fig leaf to cover the dismantling of the Soviet system of free universal healthcare, which is guaranteed in the current Russian constitution. Commercialization, critics say, will lead to a two-tier system in which the wealthy get good service in the city's proliferating private clinics and hospitals, while the poor will have to get in line for the diminishing services offered by the public sector.
"A whole public sector is being stealthily taken over, turned into a money-making enterprise, and the patients' interests will come last," says Andrei Konoval, organizing secretary of the Deystviye healthcare workers union in Moscow.
"This new emphasis on 'profitability' just means doctors will spend much more time on filling out papers than they do on treating patients," he says. "People will be driven out of the public services and forced to look for alternatives." In Russia, where the idea of for-profit medicine has virtually no public acceptance, that could be the most explosive issue of all.
Doletsky takes the view that some degree of commercialization is inevitable. He argues that many wealthy Russians already go abroad to find better medical care.
"This reform will give greater scope to private clinics to cater to people who can pay more. True, there will be a division between wealthy and less wealthy, but both sides of the system can benefit," he argues. "At the end of the day, what we want to see is everybody having access to better care. I'm convinced that this reform, though it may be painful, will leave us with that."