Health Policy and Planning Advance Access originally published online on February 21, 2006
Health Policy and Planning 2006 21(3):195-205; doi:10.1093/heapol/czl001
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Delivering babies in a time of transition in Tula, Russia
1School of Public Health and Health Management, Moscow Sechenow Medical Academy, Moscow, Russia and 2London School of Hygiene and Tropical Medicine, London, UK
Correspondence: Dina Balabanova, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK, Tel: + 44207 927 2929 Fax: + 44207 637 5391, E-mail: dina.balabanova{at}lshtm.ac.uk
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Abstract |
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Objective: To investigate the provision of maternal services in the Tula region of Russia, with an emphasis on variations in practice.
Method: The study was set in Tula Oblast. Data sources included an obstetric information database detailing all Tula deliveries in 2000 (n = 11 123) and structured interviews with the heads of maternity facilities and hospital maternity departments.
Results: Caesarean-section rates varied from 3.3–37%; episiotomy from 9–80%; and amniocentesis from 0–51%. As fertility rates fell since the 1980s, increasing numbers of women were hospitalized for ‘pathological pregnancy’ in an attempt to preserve infrastructure.
Conclusion: Over-medicalization arises in a system typified by excess capacity and large numbers of specialists. Some practice variations were correlated with characteristics of mothers, but others derive from systems structures such as equipment availability. Improvements in practice will require addressing these structural elements and steering the clinical culture towards evidence-based medicine, rather than simply writing new decrees.
Key Words: maternal health services, physician's practice patterns, practice guidelines, Russia
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Introduction |
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The marked improvement in reproductive health outcomes was among the greatest achievements of the Soviet Union in the immediate post-war period. Yet this initial progress was not sustained and, by the 1980s, infant and maternal mortality was lagging well behind Western European levels (WHO 2004
). These early gains in part reflected the creation of an extensive network of maternity facilities, under highly centralized control, ensuring virtually universal access to care that, while basic, was of uniform quality, at least in theory. This uniformity was achieved by a system of decrees or orders (prikaz) promulgated by the Ministry of Health in Moscow. The prikaz were, however, concerned primarily with the structure of the health system, providing norms for staffing, facilities and operational procedures (MoH 1980, 1981), such as frequency of visits and procedures (e.g. antenatal visits, blood tests). Prikaz were backed up by medical textbooks, approved by the Ministry of Health. However, most were written by an elite group of senior specialists, typically in national research institutes, rarely reflecting the reality of clinical practice. Soviet physicians were thus confronted with two incompatible sources of guidance: first, their own experience and, secondly, the prikaz, backed up by medical texts advocating actions that required resources rarely available to them, a contradiction that the Ministry of Health seemed unable to address. In these circumstances, chief physicians in facilities and departments were forced to apply considerable discretion, potentially leading to a much greater degree of variation than would be acceptable to the authorities. It was, however, impossible to undertake research on the extent of variation during the Soviet period.
Since the break up of the Soviet Union the scope for variation is thought to have increased further. Within the Russian Federation there has been a process of decentralization (Government of the Russian Federation 1991a), allowing regional and municipal administrations to fund and deliver health care while still formally observing the norms established by the Ministry of Health. There are also numerous local, often donor-driven, initiatives. Furthermore, there has been variable penetration of the principles of evidence-based health care that were previously rejected by the traditional Russian scientific paradigm (Chalmers et al. 1999). The standard text ‘Guide to effective care in pregnancy and childbirth’ has been translated into Russian (Enkin et al. 2000). Yet much of this work is effectively unknown and inaccessible to many Russian practitioners and, even if it was known, it may face resistance, with a desire to protect what is often seen as different traditions and ways of working that reflect available infrastructure and human resources.
In response to this perceived increase in variation, and the requirements of a compulsory health insurance system introduced in the early 1990s (Government of the Russian Federation 1991b), the Russian Health Ministry has enacted legislation seeking to standardize some clinical practices. Decrees were promulgated that established norms for treatment of individual conditions in a process of development of a basket of state-guaranteed services. The regional insurance funds introduced Medical-Economic Standards (MES), a method of reimbursement per case treated, similar to Diagnosis Related Groups, involving some standardization of treatment.
However, these applied primarily to health care paid for by regional health insurance funds while, in practice, much health care, especially in smaller local level facilities, continued to be funded mainly from municipal budgets, outside the health insurance system. This fragmentation poses particular problems for maternal health, because in some Russian regions normal deliveries are funded by health insurance (for example, Tula) while in others they are funded from municipal budgets. A decree (MoH 1998) on standards of obstetric and gynaecological care was issued in 1998 by the Ministry of Health, setting out guidance on the management of a normal delivery, yet it is not known whether this had any effect. Anecdotal evidence suggests that many central decrees never move beyond the regional health department and have little impact on clinical practice.
The overall aim of this paper was to contribute to an assessment of the ability of the Russian maternal health system to meet the challenges of the future, in particular the provision of care that is evidence-based in a context of declining birth rates. It is part of a larger study that will examine the processes of decision-making at all levels in one region. This paper first describes the structural framework within which maternal care is provided in Tula region, asking how this has responded to changing circumstances, and in particular, to a marked fall in birth rate. It then examines the clinical practices that take place within this infrastructure, focusing on the extent and nature of variation among facilities. Finally, to understand the potential for change, it assesses the regulatory framework within which care is delivered.
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Methods |
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The study was set in Tula, a region located in European Russia about 200 km south of Moscow. Tula has a population of 1.7 million, 18.5% of which live in rural areas. The region can be considered typical, in terms of its climate, geography and economic situation, of central Russia. Tula was chosen because it has poorer health outcomes, such as infant mortality (19.5 per 1000 live births in 2001 compared with 15.3 in Russia overall) (Goskomstat 2001
), and because it was the setting for the development of a computerized obstetric information system that has produced uniquely detailed data. This development focused primarily on the creation of a new system of data collection and, while the process of implementation will undoubtedly have exposed some of those involved to new ideas, it was not accompanied by any major training initiative in obstetric care. Consequently, there is no reason to believe that the practices observed are in any way atypical of Russia because of the existence of the data collection system.
Three sources of information were used. First, the regional administration maintained data on each facility providing obstetric care, with numbers of beds with different designations and numbers of funded posts and whether they are filled. Secondly, a particularly rich data source exists that provides information on the process and outcome of maternal care, including data on maternal characteristics (age, education etc.), interventions (Caesarean sections, amniocentesis, episiotomy etc.) and outcomes (birthweight, perinatal mortality etc.). This obstetric information system covered all births, of which there were 11 123 in 2000, its first full year of operation. It was developed as part of a programme for improving health care reporting that was established in Tula oblast with assistance from the Open Society Institute and the Moscow Institute of Paediatrics. The data collection system and the validation checks performed have been described in detail elsewhere (Danishevski et al. 2005). In brief, data were recorded by midwives, using three sets of structured questionnaires. The first, completed on admission, captured information on the mother and her pregnancy. The second, completed immediately after birth, recorded characteristics of the delivery and the health status of the infant. Finally, in cases of stillbirth or death within the first 7 days, a third questionnaire was completed containing details about the cause and circumstances of death. The quality and completeness of data collection was monitored throughout by the Tula region Department of Statistics through routine checks of a random sample of these questionnaires. The data quality was independently validated by comparison with information from the regional Statistics Department and the facility.
These data were supplemented by a series of structured interviews undertaken in 2002 with the heads of all stand-alone maternal facilities and obstetric departments in general hospitals in Tula. Four small facilities that have no designated obstetric beds and had less than 12 deliveries in the previous year were excluded. The final dataset included data from 19 fully operational facilities. In each general hospital the head of the obstetrics department was interviewed, as was the chief physician or their deputy in each stand alone maternal home. The subjects did not, at this stage, have access to the analyses from the database. Interviews were conducted by two interviewers with a background in social sciences and marketing research. All respondents were briefed about the goal of the study, confidentiality was ensured, and consent to participate was obtained. No-one refused to participate.
Interviews collected data about a range of medical practices recommended by international Safe Motherhood programmes. In addition, all decrees and local documents regulating maternal care were collected and analyzed. Interviews and comparison with local protocols drew on a schedule used by Khayat and Campbell in Lebanon (Khayat and Campbell 2000), adapted to the circumstances of Russia. Further information was obtained about facility characteristics, such as capacity (number of beds, staff), organization of care (rates of hospitalization of pregnant women, length of stay, referral patterns), the use of key medical procedures (such as Caesarean section, episiotomy, epidural and other types of anaesthesia), and knowledge of relevant policies guiding standards of care. Triangulation of data from the three sources was undertaken whenever possible to identify any inconsistencies. There were very few and these typically involved minor definitional or other misunderstandings that were easily addressed.
Quantitative data were analyzed using SPSS version 11.0.
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Results |
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Infrastructure and capacity
Maternal care in Tula is provided through a network of maternity homes and maternal departments in general hospitals. Maternity homes are specialized facilities independent of general hospitals. They stand alone, tend to be located in larger towns, have a greater number of staff and deliveries per year (Figure 1), and are perceived to provide better quality of care compared with the maternity departments within general hospitals. Of 19 facilities included, six are free-standing maternity homes and 13 are obstetric departments within general hospitals, each serving a designated catchment area consisting of one or more municipalities.
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Tula Oblast maternity home (the regional level facility) and Tula City maternity home provide referral facilities for complex cases, such as pregnant women with diabetes, with multiple pregnancies or with a history of birth complications. Some patients were also referred to other well-equipped facilities, such as the Novomoskovski maternity home. In 2002, 49.9% of all births in the region were concentrated in these three free-standing maternity homes.
Facilities differed in size (Table 1). The number of gynaecology and obstetric beds in free-standing facilities ranged from 95 to 230 (median 157), and from 10 to 160 (median 40) in general hospitals. The distribution was highly skewed, with three large maternity homes (>200 beds) and the rest somewhat smaller.
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To set this in context, free-standing maternity homes had an average of 238 beds overall capacity, while general hospitals had an average of 341 beds, with a minority of those located in specialized departments of obstetrics and gynaecology. A third of obstetric beds were designated as postpartum, while the rest were used for complications of pregnancy, gynaecological complaints and routine hospitalization of pregnant women. These are located in the same departments and used interchangeably where required. Facilities with greater numbers of beds had more deliveries and more staff. Overall, the ratio of midwives to obstetricians was 2.6, a ratio that was similar in facilities of different size.
As in Russia as a whole, the birth rate in Tula fell by half between 1987 and 1999 (Figure 2). The response to this change was, however, shaped by the system of financial incentives, with funding linked to bed numbers, removing incentives to rationalize infrastructure. Thus the number of maternity beds remained almost constant until 2001. As reported by interviewees, the only way to keep maternal beds filled was to change the pattern of bed use by changing the threshold for hospitalization. Consequently, there was a marked increase in the number of bed days occupied by women with poorly defined conditions such as ‘prevention of miscarriage’ and ‘pathological pregnancy’. This reflected an increase in both the percentage of expectant mothers hospitalized (up to 100% in some facilities) and the average length of time that they remained in hospital. Thus, beds previously used for deliveries were redesignated so that the number used for antenatal problems increased from 21% in 1985 to 45% of all maternal beds (pregnancy and delivery beds, excluding gynaecological) in 2001. In some facilities in areas with lowest numbers of births, all expectant mothers were hospitalized for ‘miscarriage prevention’, typically staying up to 28 days. In 2001, the regional health administration began to tackle this situation, according to interviews with head physicians, leading to a slight decrease in total bed numbers.
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In 2000, bed occupancy was 85% across facilities, and was not correlated with the number of beds or workload of the facility. Statistics related to infrastructure should be interpreted in the light of requirements of the Sanitary and Epidemiological System, which regulates infection control regimes in all health facilities. It requires annual closures of facilities for ‘washing’. Thus, every maternity facility closes for up to one month per year while sterilization and cleaning procedures are carried out, thus creating a need for more beds and lowering occupancy rates.
While the number of beds and official staffing recommendations remained constant, actual staffing levels did decline in line with numbers of deliveries. As a result, increasing numbers of officially budgeted posts have been left vacant. There were shortfalls in 16 out of 19 facilities, with the greatest discrepancies in the larger free-standing facilities; in Tula oblast maternity home there were 28 obstetricians compared with 71 budgeted posts. Novomoskovski maternity home similarly had 13 filled posts out of 27 budgeted for. Other facilities had, on average, a shortfall of three obstetrician posts.
For midwives, some discrepancies were even larger, with the Tula maternity home filling 54 of its 100 budgeted posts; elsewhere the average shortfall was five posts. For nurses, the average shortfall was three posts, except in the Tula maternity home, which filled 54 of its 127 budgeted posts. As funding is based on the number of budgeted posts, these shortfalls allow facilities to employ individuals in up to two posts, making possible a doubling of salaries (interviews with head physicians). In addition, any surplus in the salary budget could be used to contract additional administrative staff or, less often, more specialized staff (e.g. anaesthetists), who can command higher payment.
There are large differences in workload among facilities. In the free-standing maternity homes, each physician cares for, on average, between 15 and 36 inpatients (mean 23) at any time. The corresponding figures for obstetric units of general hospitals were between 12 and 20 inpatients (mean 16). Thus, in many facilities, workloads exceed the norms set by the Ministry of Health of the Russian Federation, of 15 inpatients per obstetrician (MoH of USSR 1979).
Officially, maternal care is free in Russia yet payments were reported in 11 of the 19 facilities surveyed. The question did not explicitly distinguish between formal and informal payments, but the responses received concerned only formal over-the-counter charges for ‘additional’, mainly hotel services. Payments are more commonly reported in maternal homes (83% of heads of maternal homes confirmed charges) than in general hospital departments (50% confirming charging).
Variations in clinical practice and organization of care
Rates of common obstetric procedures, such as ultrasound during pregnancy, amniocentesis, epidural anaesthesia, episiotomy, Caesarean section and the process of care (hospitalization rates and length of stay during pregnancy), were compared (Table 2). It was hypothesized that larger referral facilities or those where the workload of obstetricians (in terms of numbers of deliveries) was lower would be more ‘interventionist’ in managing pregnancy and delivery.
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There were wide variations in the rates of most clinical procedures measured, with the exception of ultrasound during pregnancy. The use of amniocentesis was especially varied. Among facilities that perform amniocentesis, maternal departments in general hospitals performed the procedure more often than did free-standing facilities (21.5% versus 17.9%, respectively, of all expectant mothers underwent the intervention at some stage in their pregnancy). Only three facilities provided epidural anaesthesia, where it was received, typically, by 10% of mothers having vaginal deliveries.
The range of procedures reported by obstetricians in different antenatal clinics was similar. Each facility offered a standard package at the first visit, including anthropometry, blood pressure measurement, ultrasound examination, risk assessment, and provision of information about delivery and labour. A blood sample was taken to test for anaemia, HIV and syphilis and for blood grouping. However, as these are not recorded on the database, we were unable to verify objectively whether all those attending received this entire package and whether there were differences by clinic in rates of early attendance (although overall attendance statistics in Tula region are high with over 90% of all pregnant women registered during the first trimester). The care provided at subsequent attendances was more varied, with some repeating the entire package at each visit, leading to some mothers receiving up to five ultrasound scans during their pregnancy.
There was greater variation in prescribing behaviour, with four facilities not offering folic acid routinely, while a further three offered it only in the second trimester, much too late for prevention of neural tube defects. The reason cited for delaying its use was concern about wasting it in cases of abortion, as well as late registration by mothers.
The obstetric practices observed differ both from the widely used international recommendations and from standards issued by the Russian Ministry of Health. For instance, the preparations typically prescribed during normal pregnancy in over half of facilities featured multivitamins for all women, while three facilities routinely recommended calcium supplements, even though the evidence is ambivalent (Kulier et al. 1998). Some advocated strict dietary restrictions (e.g. forbidding red fruits and vegetables). Several of the clinics routinely prescribed certain medicines of no proven effectiveness for all women. For example, dipyridamole was routinely prescribed to prevent eclampsia (Knight et al. 2002).
The care provided to mothers who had not delivered by 40 weeks also varied. Two facilities routinely induced labour at 40 weeks while two waited until 42 weeks, although current evidence suggests 41 weeks (Enkin et al. 2000).
All facilities included in the study reported that they do not restrict free movement during labour, however the routine use of intravenous transfusions of various, largely ineffective substances, e.g. Adenosine Tri-Phosphate, means that, in effect, many women are unable to move.
In many respects, intervention rates were higher in maternity homes than in hospital obstetric departments. For example, episiotomy rates were 37.5% in maternity homes compared with 24.4% in hospitals (p = 0.1). This was also true for Caesarean section rates, at 18.5% in maternity homes compared with 11.8% in hospital departments (p = 0.08).
A very high percentage of women were hospitalized during pregnancy but the rates were similar in maternity homes and hospital departments (76.2% and 76.5%, respectively). However, maternity homes tended to admit mothers for significantly longer periods, with a mean stay of 17.8 days, compared with 14.4 in hospitals. Contrary to what was hypothesized, there was no significant correlation between rates of Caesarean section, hospitalization or episiotomy and either facility size (bed/obstetrician numbers) or obstetric workload (ratio of deliveries to obstetricians in post).
Amniocentesis rates reflected both mother and staff characteristics. Multiple logistic regression was conducted using the 2000 data, which included individual-level variables. A range of socioeconomic variables and facility characteristics were entered using stepwise forward selection according to likelihood ratio (Table 3). The number of obstetricians was not included in the model, as it is closely correlated with bed numbers.
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The probability of having amniocentesis was strongly associated with the education (p<0.001) and age of the mother (p<0.05), with mothers under 20 years old more likely to undergo the procedure, while those who had completed higher education were less likely. When adjusted for size and type of facility, these differences persisted. General hospitals and maternal homes with over 30 maternity beds were more likely to conduct amniocentesis. It can be hypothesized that younger and less educated mothers may be viewed by health professionals as a high-risk group, or may also be less able to make an informed choice and refuse unwanted procedures.
Regulation of maternal care
The decrees setting out maternal health practices throughout Russia include older ones (MoH 1980, 1981) dating from the Soviet period, and a newer one, approved in 1998 (MoH 1998). The older ones regulate primarily the structure of care and staffing levels and are highly medicalized, for instance prescribing 12–14 antenatal visits during a normal pregnancy.
The content of the 1998 decree differs considerably from that found in guidelines from western countries (Enkin et al. 2000), not only in detail but also in general approach. The decree is notable in that it lists a variety of recommended approaches to treatment but without specifying the indications for choosing between them. For example, Caesarean sections are described without indicating when to perform the procedure. Similarly the decree describes both vacuum extraction and forceps, without mentioning the associated benefits and risks of each method. There is also no explicit description of what should take place during a normal delivery, just a list of compulsory procedures that should take place during any delivery, which could potentially create confusion among staff. However, any attempt to interpret these guidelines is complicated by the observation that, according to official statistics (Goskomstat 2001), only 31.1% of all deliveries in maternity facilities were reported as ‘normal’ in 2000.
The obligatory protocols (MoH 1998) to be used include interventions known to be either without benefit or even harmful, such as routine enema and shaving, recumbent bed position in labour, routine foetal monitoring, and use of opiates, paracervical blockade and inhalation narcosis as options for analgesia in delivery [epidural analgesia (Howell 2002) is included as an option]. The decree does not mention the use of corticosteroids in premature amniotic rupture, despite the existing evidence of their effectiveness that has led to their routine use in most other parts of the world (Crowley et al. 1990; Harding et al. 2001). Some elements of the decree are consistent with the available evidence, such as monitoring blood pressure and urinary protein, use of antibiotics after Caesarean section, and antihistamines for management of nausea and vomiting. However, many other aspects reflect a high degree of medicalization, such as dietary restrictions and repeated blood tests.
While the Ministry of Health's decree differs in important aspects from scientific evidence and internationally recognized best practice, in reality even this is rarely complied with. Although most of those interviewed knew about the existence of the 1998 decree (MoH 1998), when asked in detail about major regulations defining their practice they referred mainly to the older decrees of the Ministry of Health of the Soviet Union (MoH 1980, 1981), which provide little guidance in terms of procedures to be used. Respondents were often unable to provide examples of how the new decree informs the care they provide. In practice, most physicians’ actions were limited by resource constraints, and the availability of public funds was seen as having strong influence on clinical decisions.
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Discussion |
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Before discussing the findings of this study, we must acknowledge its limitations. Although we included all facilities providing maternal health care in Tula, the results cannot necessarily be generalized to all of Russia. Although the study includes a large number of births (11 123), there were only 19 facilities, reducing the statistical power of comparisons. Furthermore, as many of those in the facilities have shared common experiences, it is likely that, across Russia, the extent of variation may be greater. However, we believe that the broad findings of a lack of a basis in evidence for the observed policies are relevant not only to the rest of Russia, but also to other former Soviet countries with a similar inheritance and systems.
We must also recognize the possibility that there may have been some reporting bias, due to fear of disclosure of poor performance, although a detailed system of validation was put in place and any serious deception would have required interference with data flowing along several different pathways.
It should be noted that a number of individual characteristics of providers, such as age, place of education or links to influential mentors, can shape practice. This study focused on organizational characteristics, given the context of low mobility of health staff in Russia and relatively uniform medical training in Tula. Further research seeking to explore the impact of providers’ and patients’ characteristics on variability of practice in Russia is planned.
On the other hand, this is one of the first rigorous studies of the characteristics of maternal care in the former Soviet Union, combining individual and facility-level primary data. It was also able to generate hypotheses to be tested in future research.
This study demonstrates a stark contrast between the official situation, in which clinical practice is highly regulated through centrally developed guidelines, and the reality, in which there is widespread variation among facilities, with neither drawing to any significant extent on the large volume of evidence on the effectiveness of different aspects of maternal care. In practice, many of the decisions reflect the breadth of discretion given to individual clinicians, shaped also by the extent to which equipment is available. Thus, only three facilities are able to offer epidural anaesthesia, although all have ultrasound equipment, in some cases using it repeatedly. The range of rates for Caesarean section (3.3–37%) and episiotomy (9–80%) is far wider than could possibly be explained by the characteristics of the delivery.
This study paints a picture of a system that is, in many ways, resistant to formal change, with no reduction in capacity until recently despite a large decline in the birth rate, yet at the same time informally quite responsive, allowing the number of people in post to decline but compensating by increasing rewards for those remaining, while using other funds released to employ individuals for whom a need was not foreseen by the central planners.
The formal rigidity is seen in relation to skill mix, an issue that is evolving rapidly in western countries. Midwives still play a subsidiary role to obstetricians, who are in charge of deliveries, yet in some small rural facilities, especially at night, necessity requires that midwives take on extended roles, including delivery. Generally, obstetrics training in Russia does not reflect the shift towards primary and multi-disciplinary health care that has been taking place elsewhere (Tishuk and Shchepin 2003), and which would give greater responsibilities to midwives and nurses where appropriate, although there are some initiatives to redress this.
The lack of responsiveness is seen in relation to bed use, as potentially empty beds, no longer required because of the falling birth rate, are filled by a large number of expectant mothers who are now labelled as ‘abnormal’, now making up over two-thirds of the total, each staying an average of 15 days but often much longer. It is difficult to see how, for the vast majority of these women, this practice confers any benefit apart from potentially improved nutrition and shelter for mothers from disadvantaged social conditions, as well as some reduction in smoking and alcohol consumption. A recent study has, for example, shown how admission to tuberculosis facilities increases in winter as these facilities fulfill a social role to some extent (Atun et al. 2005). Moreover, it may lead to exposure to hospital infections and unneeded procedures that can cause harm.
While it is not possible, in a sample of this size, to relate the patterns of intervention in individual facilities to obstetric outcomes, it seems likely that the present situation contributes in part to the persistently poor rates of perinatal and maternal mortality seen in Russia. Furthermore, any such a comparison would have to adjust for the powerful effect of socioeconomic circumstances on birth outcomes in Russia, with other studies showing large differences in, for example, birthweight according to maternal education (Danishevski et al. 2005; Grjibovski et al. 2004). In passing, it should be noted that while the fact that less well-educated women have worse outcomes has been used by some Russian commentators to argue for the need for the more medicalized model of care, there is no evidence to support this approach.
Reform is clearly needed, in particular adjusting the size and distribution of facilities to current needs and bringing clinical guidelines, and subsequently practice, more closely into line with evidence of effectiveness. Yet it is less clear how this reform can be brought about, given the wide gap between the theory and the reality. Perhaps the first step is to recognize this gap, taking advantage of the many ‘street-level bureaucrats’ (Lipsky 1983) who are adapting their practice to changing incentives, albeit in ways that are incongruent with the wider goals of the system. This requires a new approach to management, seeing regulations as means of empowering rather than constraining individuals and developing guidance that is evidence-based, backed up by training on its application in practice, and which is consistent with a set of clear and achievable goals that all involved can sign up to (Preker et al. 2006).
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Biographies |
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Kirill Danishevski, MD, MPH, is a Lecturer at the School of Public Health and Health Management, Moscow Sechenow Medical Academy, Russia and a Research Fellow at the London School of Hygiene and Tropical Medicine, UK. Before joining the DFID Health Systems Development Programme, he had been teaching public health, health systems and epidemiology at the postgraduate department of Moscow Medical Sechenow Academy since 1999. In 2000 he joined the Open Society Institute (Soros Foundation – Moscow) as a consultant to public health programmes. The projects designed included implementation of general practice, development and dissemination of evidence-based clinical recommendations, improvement of the system of credentialing and accreditation. In addition, he undertook a number of short-term consultancies in several transitional countries: Georgia, Uzbekistan and Moldova. Current research areas include the determinants of clinical practices and levers to changing them, decentralization and the political process underlying current reforms in Russia, such as re-strengthening the role of the Ministry of Health.
Dina Balabanova, MPH, PhD, is a Lecturer at the London School of Hygiene and Tropical Medicine (LSHTM), UK. Before joining the DFID Health Systems Development Programme, she had previously worked on health financing reform in Bulgaria, based at LSHTM (EU PHARE project; PhD) and in development assistance, as Oxfam's regional policy adviser for the Former Soviet Union and Yemen. She has a background in sociology and social policy, and since 1995, in health policy and health sector reform mainly in the transition countries of Eastern Europe and the former Soviet Union. Current research areas are understanding health systems responses to conditions requiring complex inputs (TB, diabetes, maternal care, cervical cancer), access to care and its determinants, as well as health sector restructuring (hospitals in Bulgaria, primary health care reform in Russia, and community-based financing in Armenia).
Martin McKee, CBE, MD, FRCP(UK), FRCPI, FFPH, FMedSci, is Professor of European Public Health at the London School of Hygiene and Tropical Medicine, UK, where he co-directs the School's European Centre on Health of Societies in Transition. He is also a research director in the European Observatory on Health Systems and Policies
Justin Parkhurst, M.Phil, D.Phil, is a Lecturer at the London School of Hygiene and Tropical Medicine, UK. His research areas include maternal health and health systems, and HIV/AIDS policy and prevention. He holds a D.Phil (Sociology and Social Policy) and an M.Phil (Development Studies) from the University of Oxford, and a BS from the University of Pennsylvania.
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Acknowledgements |
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The authors are members of the Health Systems Development Programme, which is funded by the UK Department for International Development (DFID). DFID supports policies, programmes and projects to promote international development. DFID provided funds for this study as part of that objective but the views and opinions expressed are those of the authors alone. The development of the information system in Tula was funded by the Open Society Institute.
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References |
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