Health systems reform in the Russian Federation remains and will continue to present a major challenge in the short and medium terms. The Russian Federation inherited a publicly funded health system that ensured universal entitlement to a broad package of health services, as well as an extensive network of hospitals and public health facilities. This system was characterized by overreliance on curative and inpatient care, with incentives that encouraged providers to hospitalize patients for lengthy periods. While this system worked well for managing communicable diseases in the decades that preceded the political and economic changes of the 1990s, it has been less adept at responding to an epidemiological profile dominated by noncommunicable diseases, particularly high rates of cardiovascular diseases, injuries and the new communicable disease challenge of human immunodeficiency virus (HIV). The system also successfully struggled with controlling tuberculosis (TB), and the struggle worsened in the last two decades. At the turn of the millennium, the Ministry of Health and Social Development of the Russian Federation, with support of the World Bank, launched a pilot project to infuse financial resources and technical assistance into two regions southest of Moscow: the Chuvash Republic and the Voronezh Oblast. These efforts at the regional level were supported by policies and initiatives at the federal level. During the ensuing years, laws were passed to support health system reforms, investments were made to improve infrastructure and equipment, and the health care provider incentive framework was adjusted to encourage improvements in the delivery of health services. This report presents the first evaluation of the Russia Health Reform Implementation Project (HRIP). At its core, the evaluation explored the changes achieved as a result of the HRIP in the key health system functions: governance and structural organization, financing, service delivery, resource generation, and monitoring and evaluation. The study analyzed structural changes — for example changes in number of hospital inpatient beds, creation of new outpatient facilities, increase in number of general practice (GP) centers — as well as shifts in service delivery towards a more extensive utilization of primary health care services. Service provision in the newly established GP centers and the scope of care delivered by general practitioners were mapped respectively using a facility survey and a task profile survey of general practitioners working at the primary care level. Finally, a user satisfaction survey was undertaken in the GP centers to ascertain their satisfaction with the services provided at the primary care level. The reports findings are promising in several key areas as progress has been made in many indicators. For example, in both regions, outpatient facility capacity has grown slightly, while the number of general practices has grown impressively. Financing arrangements have evolved such that financing for health care from the federal, regional and local governments has nearly doubled. Perhaps more important, spending on primary health care, as opposed to specialty care, has risen impressively. After new training the percentage of the population with access to general practitioners, has risen from 13% and 3% to 41% and 28%, respectively, in Chuvash Republic and Voronezh Oblast. The primary audience for this report consists of policy makers, analysts, managers and health service providers in the Russian health sector. A secondary audience is internal, particularly managers and staff of the World Bank who are working in the Russian Federation and other middle-income countries. Governance Both regions have strengthened primary health care through new laws and regulations establishing an environment geared to sustainable primary health care, health promotion, disease prevention and appropriate resource use. New governance arrangements allow more flexibility in GP employment practices so regional authorities can attract and retain these healthcare providers. Structural Organization PHC services have been restructured, creating general (family) practices units that provide care for users of all ages and gender for all common conditions. Structural reforms, such as transforming some hospitals into long-term care units or GP facilities with urgent care units have helped to rationalize excess hospital infrastructure and bed capacity. This has been particularly important for improving the accessibility to health services for the rural population and the elderly. Innovative approaches to health services delivery, such as the establishment of day care centers for outpatient surgery, diagnostic and other services, have been developed. Financing Additional funding have supported the health system restructuring effort by improving physical infrastructure, replacing and updating medical equipment and managing information systems, strengthening the communications, transportation, and response capacity of emergency medical services, training of health staff, and developing quality improvement and incentive systems, including regional health accounts that are helping monitor the financial flows within the health system. And the introduction of provider payment methods is encouraging better provider performance. Service Delivery In both pilot regions health services provided by the PHC level has increased as inpatient care is gradually substituted by outpatient care services, including GP services, day care hospitals, outpatient surgery centers, and home-based services. Both regions have invested substantially to improve PHC infrastructure with construction of new centers, repair of existing facilities and purchase of new, modern medical and diagnostic equipment to improve accessibility and quality of services. Quality assurance systems and guidelines have been introduced to encourage the efficient and appropriate use of new diagnostic equipment, and delivery of effective PHC services to meet increased demand due the secondary to primary shift. Health Delivery Networks supported by management information systems and information technology platform, linked to the MHI funds in both regions has been instrumental in the reform process contributing effectively to: the implementation of performance based provider payment systems monitored and intervened through appropriate performance management systems; emergency medical services supported by state of the art automated central dispatch network with improved emergency response and pre-hospital care health delivery networks conformed by polyclinics, municipal health facilities and Inter-rayon health facilities and dispatch centers integrated through broadband wide area networks with the regional reference centers and regional health authorities inter and intra regional online video clinical consultation and training based telemedicine networks piloting of the financial model and national health accounts patient based clinical case management and referral systems supported by a network of PCs and peripheral equipment installed in GP offices linking the GP offices to the rayon and Inter-rayon hospitals; disease registries and surveillance systems supported by the IT platform; and family passport data collected at the point of care used to measure and reward performance based in the provider payment systems.
Resource Generation There has been substantial investment in developing human resources in PHC and the health system as a whole. Both regions have introduced dedicated training programmes for general practitioners and nurses and have also outsourced training from leading centers in Russia. In addition to retraining of doctors and nurses working in PHC in family medicine, continuing professional development programmes have been introduced to update the knowledge and skill base of the doctors working at PHC level. Managerial capacity has been strengthened in both regions at all levels of the system through the training of personnel to implement the reforms and sustain change. Monitoring and Evaluation A range of interrelated initiatives has been introduced to improve the quality of services. Continuous quality improvement programs have been established in both regions, with quality targets at regional, rayon, hospital, PHC and individual health worker level. The achievement of these targets are benchmarked against past performance and levels achieved in the Russian Federation. Both regions have implemented new care guidelines developed at federal level to enhance the quality of services delivered and to optimize referrals to hospitals. These guidelines have been adapted regionally, taking into account specificities of local contexts. The quality improvement initiatives have been underpinned byinvestment in clinical and managerial health information systems to capture timely and relevant data at provider and managerial levels to improve the quality of clinical managerial and decisions. Conclusion The achievements in Chuvash Republic and Voronezh Oblast demonstrate that it is possible to restructure regional health systems to address emerging public health challenges faced by the Russian Federation. These case studies provide much needed evidence of success and rich local experience to inform regional health system strengthening efforts in other regions of the vast Russian Federation. |
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