In large measure, this is due to therelatively low level of public health spending in thecountry (about 3.6 percent of gross domestic product (GDP)in 2008) that underlines the significant gap between theconstitutional commitment to a range of medical careservices and the actual funding to pay for them. While drugsare supposed to be provided to hospital patients free ofcharge, an estimated 80 percent of inpatients still have topay part of the costs of their medicines and mostoutpatients must purchase them from pharmacies. Theoutpatient drug program under mandatory health insurancecovers only around 16 million people (11 percent of thetotal population in the country), with more than half ofthem opting to receive cash rather than in-kind benefitsunder the 2005 'monetization' of prescription drugbenefits. Those who continue with the in-kind benefitsappear to be the ones greatest in need of drugs. Thesituation is further aggravated by the country'sineffective enforcement of controls on wholesale and retailmark-ups for medicines. Household expenditure on drugsaccounted for about 30 percent of total health expenditurein Russia, as compared to 12 percent in Organization forEconomic Co-operation and Development (OECD) countries in 2008.
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