Health care reform in Russia

The break-up of the former Soviet Union has created a greater realisation of the health and health care deficiencies of what are now independent states and the need for reform. The purpose of these two papers is to describe these deficiencies and set the scene for the establishment of some form of national health insurance in Russia and the other states in the near future. The level of infant mortality across the former Soviet Union in 1990 was 21.8 per thousand. This average disguised wide regional variations, from 32 to 55 per thousand in the rural areas of Middle Asia to 11 to 18 per thousand in the more economically developed areas of the Baltic Republics, Russia, Byelorussia and the Ukraine. Average life expectancy in 1989 was 69.5 years, 64.6 years for men and 74 years for woman, and there were significant regional variations. The major cause of death is cardio-vascular disease and there is evidence not only of late diagnosis of disease but also of a large proportion of chronic diseases being undetected. During the 1980s the health service expanded: more doctors were employed, the hospital bed stock increased and outpatient clinic capacity rose. The rate of hospitalisation is high and the utilisation of facilities us poor e.g. average length of stay exceeds 15 days. Any reforms will need to change the funding of health care and im prove the efficiency of the delivery system. Thus reformers are discussing the decentralisation of management functions away from the centre to the regions, improvements in management training, and improved coordination between the primary and secondary parts of the health care system. Experiments involving decentralising budgets being related to activity and outcome goals have been carried out in various parts of Russia. In Russian, legislation has been passed to introduce health insurance from January 1st 1993. The fine detail of this scheme, even at this late stage, is still undecided. Furthermore the infrastructure to collect and distribute funds has not been created. Further legislation has been introduced which separates consumers, purchasers and providers. The health and health care problems in Russia and other parts of the former Soviet Union are great and the ambitions for reform are well articulated at the level of principle. However, the translation of these principles into practice, when the economy is facing high levels of inflation and decreasing output, and when the administrative structures to facilitate the finance and management of the proposed decentralisation system are absent, is a mammoth task. These papers demonstrate that Russian academics and policy makers recognise these problems and are rising to the challenge of resolving them.