Health Policy and Planning Advance Access originally published online on February 24, 2006
Health Policy and Planning 2006 21(3):183-194; doi:10.1093/heapol/czl002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The fragmentary federation: experiences with the decentralized health system in Russia
1School of Public Health and Health Management, Moscow Sechenow Medical Academy, Moscow, Russia, 2London School of Hygiene and Tropical Medicine, London, UK and 3University of Manchester, Manchester, UK
Correspondence: Kirill Danishevski, MD, MPH, Lecturer, School of Public Health and Health Management, Moscow Sechenow Medical Academy, 109507 Moscow. E-mail: kirill.danichevski{at}lshtm.ac.uk
The Russian Federation has undergone a process of major constitutional change in the post-communist period, as a strong central government has ceded extensive powers to the regions. This has important implications for the organization of the health care system which, as with other elements of the Soviet system, had previously been highly centralized. Although it is now well-recognized that the powers of the Federal Health Ministry have weakened considerably, the precise scale and nature of the process of decentralization remain imperfectly understood. This paper provides new evidence on the nature of decentralization in the Russian Federation since the breakdown of the USSR, reporting the results of case studies undertaken in six regions of Russia (Samara, Tver, Tula, Chelyabinsk, Sverdlovsk and Moscow oblasts) to describe the organization of health care financing, regulation and delivery. It shows that while there is a common model of health system (with the exception of Samara, where an innovative model was implemented), there are many minor variations. The study confirms the limited scope for action by Federal authorities, but also shows that the power vested in the regional governments is more limited than was previously thought. Instead, the municipalities (rayons) emerge as important bodies, as they own the facilities in which much of the routine health care is delivered and, both directly and indirectly, by virtue of their contributions of insurance premiums for the non-working, provide a substantial amount of health care financing. The study demonstrates the complexity of the Russian health care system and identifies the widespread absence of mechanisms that might be used to bring about much needed change.
Key Words: decentralization, Russia, local government, ownership, finance
1Throughout the paper the term region will be used to refer to any of the decentralized administrative units: oblasts, krays, republics, autonomous areas, cities of federal significance.
2The term municipality will be used throughout the paper for this administrative level.
3The compulsory medical insurance system comprises a series of semi-independent organizations: a federal fund, 90 territorial funds and private health insurance companies. The territorial funds collect premiums through their branches and distribute them through private insurance companies who in turn contract service providers. In 1999, there were 1174 branches of the territorial funds and 424 private insurance companies (Taranov 1999).
4Voluntary medical insurance exists mainly in the wealthier areas, such as Moscow and Saint Petersburg, and where oil or other large enterprises are the main employer. However, even in these cases the overall contribution is small. Reports from insurance companies suggest that in Moscow, only about 100 000 of a population of 10 million have private insurance; in St Petersburg the numbers are about 56 000 out of about 6 million (Dimkin and Lineva 2002).
5Samara is an exception to this rule amongst our case studies.
6There is no requirement for federal approval of the head of the oblast health authority.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. Aarva, I. Ilchenko, P. Gorobets, and A. Rogacheva Formal and informal payments in health care facilities in two Russian cities, Tyumen and Lipetsk Health Policy Plan., September 1, 2009; 24(5): 395 - 405. [Abstract] [Full Text] [PDF]
|
|