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The HiT on the Russian Federation was produced by the EuropeanObservatory on Health Systems and Policies. This edition was writtenby Larisa Popovich, Elena Potapchik, Sergey Shishkin, Erica Richardson,Alexandra Vacroux and Benoit Mathivet. It was edited by Erica Richardsonand Marina Karanikolos of the Observatory’s team at the London School ofHygiene & Tropical Medicine. Martin McKee was the Research Director forthis publication. The basis for this edition was the previous HiT on the RussianFederation which was published in 2003, written by Ellie Tragakes and SuszyLessof, and edited by Ellie Tragakes.The Observatory and the authors are particularly grateful to PatricioMarquez (the World Bank), Luigi Migliorini (WHO) and Kirill Danishevskiy(Russian Society for Evidence Based Medicine) for reviewing the report andfor their important contributions.Special thanks go also to the WHO Country Office team in Moscow fortheir assistance in providing information and for their invaluable comments onprevious drafts of the manuscript and suggestions about plans and current policyoptions in the Russian health system, and to Oleg Chestnov of the Ministryof Health and Social Development for his assistance in the preparation ofthis report.Thanks are also extended to the WHO Regional Office for Europe for theirEuropean Health for All database from which data on health services wereextracted; to the OECD for the data on health services in western Europe; andto the World Bank for the data on health expenditure in central and easternEuropean countries. Thanks are also due to national statistical offices thathave provided data. The HiT reflects data available in September 2011, unlessotherwise indicated.The European Observatory on Health Systems and Policies is a partnershipbetween the WHO Regional Office for Europe, the Governments of Belgium,Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and theAcknowledgementsAcknowledgements

viiiHealth systems in transition Russian FederationVeneto Region of Italy, the European Commission, the European InvestmentBank, the World Bank, UNCAM (French National Union of Health InsuranceFunds), the London School of Economics and Political Science, and the LondonSchool of Hygiene & Tropical Medicine. The Observatory team workingon HiTs is led by Josep Figueras, Director, Elias Mossialos, Martin McKee,Reinhard Busse and Suszy Lessof. The Country Monitoring Programme ofthe Observatory and the HiT series are coordinated by Gabriele Pastorino.The production and copy-editing process of this HiT was coordinated byJonathan North, with the support of Caroline White, Jane Ward (copy-editing),Pat Hinsley (typesetting) and Aki Hedigan (proofreading).

CISCommonwealth of Independent StatesDLOSupplementary Medicines Provision(Dopolnitel’noe Lekarstvennoe Obespechenie)EMLEssential and Most Important Medicines ListEUEuropean UnionFAPFeldsher–midwife posts(Feldsher-akusher punkt)FMBAFederal Medical and Biological AgencyGDPGross domestic productGMPGood manufacturing practiceGPGeneral practitionerHIVHuman immunodeficiency virusINNInternational nonproprietary nameITInformation technologyMHIMandatory health insuranceNGONongovernmental organizationNPPHNational Priority Project – HealthNPSNew Payroll SystemOECDOrganisation for Economic Co-operation and DevelopmentONLSScheme for provision of necessary medicines(Obespechenie neobhodymyh lekarstlennymi sredstvami )PGGProgramme of State Guarantees for Medical Care Provision Free of ChargeRLMSRussian Longitudinal Monitoring SurveyRospotrebnadzorFederal Consumer Right Protection and Human Wellbeing Surveillance Service(Federal’naya sluzhba po nadzoru v sfere zashtity prav potrebiteley i blagopoluchiya cheloveka)RoszdravnadzorFederal Service on Surveillance in Healthcare and Social Development(Federal’naya sluzhba po nadzoru v sfere zvdravoohraneniya i sotsial’nogo razvitiya)TBTuberculosisUNICEFUnited Nations Children’s FundVHIVoluntary health insuranceVZNScheme for high-cost conditions (Vysokozatratnye nozologii)WHOWorld Health OrganizationWTOWorld Trade OrganizationList of abbreviationsList of abbreviations

List of tables, figures and boxesList of tables, figures and boxesTables pageTable 1.1Trends in population/demographic indicators for the Russian Federation, selected years 2Table 1.2Macroeconomic indicators, selected years 4Table 1.3Mortality and health indicators, selected years Table 1.4Main causes of death (all ages per 100 000 population), 1990–2009 (selected years) 11Table 3.1Health expenditure trends in the Russian Federation, 1995–2009 (selected years) 69Table 3.2Sources of revenue as a percentage of total expenditure on health,1995–2009 73Table 3.3Out-of-pocket expenditures on fee-paying services and purchasing drugs (billion roubles),2000–2009 86Table 3.4VHI contributions, 2000–2009 88Table 4.1Network of medical facilities, 1990–2009 96Table 4.2Condition of health facility buildings, inpatient and outpatient 96Table 4.3Capital investment by source of funding (excluding small enterprisesand informal economic activities), 2005–2008 97Table 4.4Number of hospital beds by specialty per 10 000 population 98Table 4.5Number of physicians per 10 000 population, 1990–2009 102Table 4.6Number of midlevel health personnel per 10 000 population by category, 1990–2009 104Table 5.1Long-term medical and social care provided by social protection facilities, 2004–2009 132Table 5.2Mental health services provided under the health system,resources and utilization, 2000–2008 (selected years) 135Table 5.3Network of social protection facilities providing mental health servicesfor adults, 2004–2009 135Table 5.4Dental care services provided in state and municipal medical facilities, 2000–2008 136Table 6.1Expenditure on the NPPH, 2006–2010 139Table 6.2MHI contribution rates (% of the payroll fund under the generaltaxation scheme), 2009–2012 15110

xiiHealth systems in transition Russian FederationFigures pageFig. 1.1Map of the Russian Federation Fig. 2.1Overview of the Russian health system 14Fig. 3.1Total health expenditure as percentage of GDP, WHO estimates, 2008 68Fig. 3.2Trends in health expenditure as a share of GDP in the Russian Federationand other selected countries from 1990 to latest available year 69Fig. 3.3Health expenditure per capita (US purchasing power parity)in the WHO European region, 2008 702Fig. 3.4Public sector health expenditure as a percentage of total health expenditurein the WHO European Region, 2008 71Fig. 3.5Percentage of total expenditure on health according to source of revenue, 2009 72Fig. 3.6Financial flows 74Fig. 3.7Health care funds pooled in the budget system and in the MHI system 81Fig. 3.8Percentage of patients who paid for different types of health serviceamong people seeking this type of service in 1994–2009 85Fig. 3.9Percentage of patients paying for necessary health care,outpatient and inpatient, informally 87Fig. 3.10The share of the Russian population (aged 13 years and older) with a VHI policy 88Fig. 4.1Beds in acute hospitals per 1000 population in the Russian Federationand selected other countries, 1990 to latest available year 99Fig. 4.2Number of physicians per 100 000 population in the Russian Federationand selected other countries, 1990 to latest available year 103Fig. 4.3Number of nurses per 100 000 population in the Russian Federationand selected other countries, 1990 to latest available year 104Fig. 4.4Number of physicians and nurses per 100 000 population in the WHO European region, latest available year 105Fig. 4.5Number of dentists per 100 000 population in the Russian Federationand selected other countries, latest available year 106Fig. 5.1Outpatient contacts per person in the WHO European region, latest available year 117Boxes pageBox 3.1Health financing innovation in the Chuvash Republic Box 5.1An example pathway in the provision of medical care 113Box 5.2Reforming primary care in the Chuvash Republic 118Box 5.3Reorganizing inpatient care in the Chuvash Republic 12182

The HiT reviews are country-based reports that provide a detaileddescription of a health system and of policy initiatives in progress or underdevelopment. HiTs examine different approaches to the organization,financing and delivery of health services and the role of the main actors inhealth systems; describe the institutional framework, process, content andimplementation of health and health care policies; and highlight challengesand areas that require more in-depth analysis.At independence from the Soviet Union in 1991, the Russian health systeminherited an extensive, centralized Semashko system, but was quick to reformhealth financing by adopting a mandatory health insurance (MHI) modelin 1993. MHI was introduced in order to open up an earmarked stream offunding for health care in the face of severe fiscal constraints. While the healthsystem has evolved and changed significantly since the early 1990s, the legacyof having been a highly centralized system focused on universal access to basiccare remains.High energy prices on world markets have ensured greater macroeconomicstability, a budget surplus and improvements in living standards for most of theRussian population. However, despite an overall reduction in the poverty rate,there is a marked urban–rural split and rural populations have worse healthand poorer access to health services than urban populations. The increase inbudgetary resources available to policy-makers have led to a number of recentfederal-level health programmes that have focused on the delivery of servicesand increasing funding for priority areas – including primary care provisionin rural areas. Nevertheless, public health spending in the Russian Federationremains relatively low given the resources available. However, it is also clearthat, even with the current level of financing, the performance of the healthsystem could be improved. Provider payment mechanisms are the main obstacleto improving technical efficiency in the Russian health system, as most budgetAbstractAbstract

xivHealth systems in transition Russian Federationfunding channelled through local government is input based. For this reason,the most recent reforms as well as legislation in the pipeline seek to ensure allhealth care funding is channelled through a strengthened MHI system withcontracts for provider payments being made using output-based measures.

IntroductionThe Russian Federation is the largest country in the world by surface areaand covers over 17 million km 2 spanning both Europe and Asia. Thecountry is rich in natural resources, having major deposits of oil, naturalgas, coal, timber and many strategic minerals. Exploitation of these naturalresources is central to the country’s economy. After the economic instabilityof the 1990s, following the dissolution of the Soviet Union, the economy grewsteadily, accompanied by moderate inflation, a balanced budget and significanttrade surplus. Poverty rates in the cities fell rapidly as the macroeconomicsituation improved, but the urban–rural divide also widened to the extent thatby 2004 poverty had become a largely rural phenomenon. The sustainability ofthe oil-price-driven economic recovery has been severely challenged since 2008with the global economic crisis and resultant fall in global fuel prices.The population of the Russian Federation peaked in 1992 at 148.3 millionand it has been shrinking ever since. This has been caused by a falling fertilityrate and relatively low birth rate coupled with a high death rate. The low birthrate and low fertility rate are common to other post-Soviet countries; however,the high death rate has been more severe in the Russian Federation than inneighbouring states, and it has most seriously affected men of working age.Life expectancy in the Russian Federation declined strongly following thedissolution of the Soviet Union in 1991, but almost recovered by 2009. It hasbeen shown that these fluctuations are not artefact and there is very strongevidence that alcohol consumption, including the consumption of non-beveragealcohol, played a key role in the initial decline in life expectancy, and continuesto have a detrimental impact on population health.Executive summaryExecutive summary

xviHealth systems in transition Russian FederationOrganization and governanceThe Russian health system inherited its infrastructure from the Soviet Union,and adopted a MHI model in 1993 in order to open up an earmarked streamof funding for health. While the organization and governance of the healthsystem have evolved and changed since independence, the legacy of havingbeen a highly centralized system focused on universal access to basic care stillinforms much of the discourse and practices in the system.The Ministry of Health and Social Development (MoHSD) with its associatedfederal agencies and services (particularly Rospotrebnadzor (Federal ConsumerRights Protection and Human Wellbeing Surveillance Service) Roszdravnadzor(Federal Service on Surveillance in Healthcare and

World Health Organization Country Office in Tajikistan. Health . System Review. 2011. Russian Federation: The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the . Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia,