Evolution and Prospects of Compulsory Health Insurance in Russia[Эволюция И Перспективы Системы Обязательного Медицинского Страхования В России]

The paper analyzes the transformation in Russian compulsory health insurance (CHI) over the thirty years of its existence and highlights the changes in the mechanisms of state, societal and market regulation used to perform the three main functions of the healthcare financing system: i) collection of financial resources, ii) pooling and allocation of financial resources, iii) purchasing of medical care. These changes are interpreted as institutional responses to challenges in making healthcare financing operate in a stable and efficient way. The Russian CHI system has evolved from an attempt to base it on a combination of state, societal and market regulation into almost complete dominance by the state. The initially heralded creation of a competitive CHI model succumbed to practical obstacles such as the lack of market institutions in the overall economy and the time-restricted window of opportunity for implementing market reforms. This led to modifications in the design of the CHI model and to replacement of regulation by societal and market institutions with regulation by state institutions. From that point on, the government policy toward CHI has been aimed at strengthening centralized state regulation of the CHI system. The future development of the Russian CHI system will require resolving this key institutional contradiction in its design. The choices are: a) continue replacing the remaining market and societal regulatory mechanisms with administrative regulation and using the tools of the latter to ensure more sustainability and efficiency in the CHI system; or b) try strengthening market and societal regulation of the CHI system, and especially the role of health insurers, and thereby increase their impact on the effectiveness CHI. These two alternatives point to two possible scenarios for the future implementation of CHI in Russia.