It is well known that the USSR and modern Russia have a significantly higher number of hospital beds compared to other European countries (1 225 370 hospital beds: 143 347 059 per capita, or 855 beds per 100 000 capita in Russia vs 504 hospital beds in old members of the EU). The Russian government have tried to reduce expenses in the hospital sector, but the number of beds as well as hospitalization has not reduced significantly during the past 20 years. The hospitalisation rate per 100 capita also has not reduced (21.8 in 1991 and 21.9 in 2011).

The government has been trying to move more healthcare to an outpatient setting so it has pressed healthcare organisations to expand day care and other forms of substitute inpatient care. Large sums of money were spent trying to improve the “material base” of outpatient care as well as inpatient facilities. The significant investments in equipment did not produce visible results. The reasons are all unpleasant for the government to explain. The quick fix of investing in new equipment was not paralleled by doctors’ training, and expensive equipment is underused, for example they invested in an enormous number of tomographs etc. Much of the equipment is still waiting to be installed; patients are still keen to be treated in hospital, and primary care physicians are not interested in ambulatory treatment (the capitation payment system, which pays doctors for the number of patients they see, is yet to be introduced almost everywhere in Russia).

This August the internet community, the the print media, and TV media were shocked by reports that Moscow’s ambulance service does not get sick people to hospital, but only reports them to polyclinics. In one case, in late August, a man did try to get access to hospital care, called an ambulance three times, visited a polyclinic a couple of times, and when hospitalized had a toe amputated because of osteomyelitis. The explanation for the unprecedented behavior of the ambulance service was an order signed by the chief of the Moscow ambulance service. Literally this order (no. 374), signed on 7 August, states that ambulance staff should arrange for patients to be treated in polyclinics. In reality ambulance staff can take patients to hospital only after it has been approved by the ambulance station. Patients with listed conditions–from urine retention to acute quickly progressing glomerulonephritis—are blocked from hospitalisation.

The federal ministry of health announced that this order needs to be investigated and that there is no need to limit the hospitalisation of patients. The ministry said that they did not demand that regional governments reduce the number of patients that are admitted to hospital. In the end the federal healthcare controlling body, RosZdravNadzor, prohibited the use of this regulation of the Moscow ambulance service.

We do not know how effective this order has been. What we can learn from censored data (the data from certain days is missing on the website of Moscow’s ministry of health), is that while the number of ambulance rides was quite stable (7959 per day as of 31 July and 7763 per day as of 23 August) the number of people hospitalised dropped in the city from 2196 to 1730 per day. We can only wonder what had happened to the people, who were not hospitalised.

The real cause of the high hospitalisation rate in Moscow, as well as in whole Russia, is that people need to buy drugs for ambulatory care from their own pocket. In hospitals drugs are free, at least most of the time. Drugs are not cheap in Russia, and about 50% of the population report in polls that buying drugs has a severe effect on their family budget.

This is not a secret for the Russian government. Russian economists have even calculated how much it would cost to provide drugs for free in ambulatory care. It is not so much. But the decision is being blocked by government, who does not believe that it can manage the programme. In 2005, a small programme of free drug delivery to people receiving social support was so badly arranged that it forced hundreds of thousands of people on the streets in protest. This is the real cause—the Russian government carries out small fixes instead of proper healthcare reform.

Vasiliy Vlassov is a Professor of medicine at the Higher School of Economics, Moscow. His research interests are in epidemiology, evaluation of diagnostic tests, public health, and especially health care delivery with scarce resources. He is the co-founder and current president of the Russian Society for Evidence Based Medicine.