The following is a guest post by Brittany Holom, a Ph.D. candidate in the Department of Politics at Princeton University.
On Nov. 30, medical personnel, activist groups, and political parties gathered in Moscow, the noise slowly growing louder as group after group joined the marching line, using loudspeakers to project their chants into the biting winter air. The demonstrators’ signs called for a moratorium on proposed reforms to the city’s health-care system, with some demanding to know why there was money for war, but not for medicine. News agencies estimated that 5,000-6,000 people braved the day’s freezing temperatures to demand accessible, affordable medicine (dostupnaya meditsina). These protests against planned health-care reforms in Moscow marked the second event of its kind within the month; the first “doctors’ meeting” had taken place on Nov. 2. Another took place on Dec. 14, in combination with groups against education reforms. What are these reforms that have drawn such opposition, and why have these specific protests gained so much attention? What do they mean for the Putin regime, particularly in the context of the larger economic woes? Could widespread support for the welfare state prove to be a stumbling block for Putin’s popularity?
The recent protests are rooted in Moscow health reform plans that first emerged in mid-October, when Russian Medical Server, an online medical news site, leaked the details of the intended changes to the city’s health care. To optimize the system’s structure, it was reported, the government planned to close 28 hospitals and clinics in the city and lay off thousands of medical personnel. According to the groups of doctors and nurses gathered at the rallies, the planning process took place behind closed doors for months, with little to no consultation with those working day-to-day in the city’s health-care system. Moscow officials later reported that the government’s Research Institute of the Organization of Healthcare and Medical Management had authored the reforms.
While the specific characteristics and plans of the reforms in question are new, the push for change is not. Since the dissolution of the Soviet Union, analysts have argued that the Russian health-care system is in dire straits. It has struggled against a long history tied with alcoholism and issues of underfunding and structural imbalances linked with the legacies of the Soviet Semashko system. Nevertheless, although the goal of improvement has been constant across time and regimes in post-Soviet Russia, there has been little clear, strong direction for achieving this. Then, in his 2012 “May Decrees” pledges, Putin promised a full restructuring of the system to meet updated health goals. The government immediately began planning for a shift of health-care financing to “single-channel” funding, which will begin in 2015. In April 2014, deputies approved an update of the state program “The Development of Healthcare,” which laid out strategies for advancing the Russian health care system. These strategies largely followed the recommendations and goals set out by the World Health Organization (WHO). The current Moscow reforms are part of this larger drive for greater efficiency and improved health.
While health-care reforms are frequently controversial, they are not often considered to threaten he stability of a regime, particularly in a country where, in July 2014, the Pew Research Center found that 83 percent of the population expressed confidence in Putin to “do the right thing regarding world affairs” (compare that with the rest of countries included in the Global Attitudes Survey, of which only a handful expressed more than 50 percent confidence). Even as recently as the end of November, in the midst of international tensions and emerging economic woes, the Moscow-based Levada Center, which conducts public opinion polls and sociological research in Russia, found that approval ratings for Putin still stood at 85 percent.
If Putin is so popular, why have these reforms led to such large protests? Despite the reports on the struggles of the Russian health-care system, research has shown that health care – and the welfare state in general – is one area on which post-communist populations have maintained an unwavering and strong consensus since the fall of the Soviet Union. The belief in the government’s responsibility for providing quality health care continues to dominate expectations. The Levada Center’s findings over the past two months further corroborate this claim, showing that, although overall support for protest activities has decreased in recent months, the only protests continuing to receive widespread support from the population are these “doctors’ protests” against health-care reform. According to the Center’s deputy director, it appears that citizens will more actively protect their expectations in health care and education, which affect their everyday lives, than they will in the case of more “symbolic laws,” such as those addressing larger macro-economic issues or international affairs. Furthermore, Russia is a country where the vast majority of medical personnel are state employees, meaning that unrest over reforms can signify trouble at that crucial intersection between the state and the public, which can in turn serve as an opportunity for some political concessions in the domestic sphere. This indicates that, more than anything else, social sector reforms could prove to be a challenge for Putin and his government. Perhaps that is why Putin used his State of the Nation address on Thursday, Dec. 4 to focus on international issues, and answered only one question about health-care reform at his end-of-the-year press conference on Dec. 18.
With the ruble collapsing, new bans on imports announced weekly, the continuing Ukraine crisis, and additional sanctions being considered by the West, domestic unrest has taken a backseat in media coverage to international and economic concerns. However, movements against social sector reforms – and in particular these “doctors’ meetings” – appear to be where real political compromise may occur in Russia. Putin himself has already begun to backtrack on the health-care reforms, indicating that he believed that authorities had not considered all of the nuances of the reform plans and that further deliberation is needed before they are fully implemented. Therefore, it seems that the welfare state may prove to be a significant bargaining chip for the Russian population, a chip that will only grow stronger with continued hardships under economic and international policies.