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Brief analytical summaries or syntheses #37

Russian Federation – Health System Review.
Health systems in transition, 2011


The WHO produces health system profiles (HiTs), which are country-based reports providing a detailed description of health systems and policy initiatives. This HiT on the delivery of health care in Russia examines different approaches to the organization, financing and delivery of health services in that country, along with the roles of main local actors.


At independence from the Soviet Union in 1991, the Russian health system inherited an extensive, centralized Semashko system, but was quick to reform health financing by adopting a mandatory health insurance (MHI) model in 1993. While the health system has evolved and changed significantly since the early 1990s, the legacy of having been a highly centralized system focused on universal access to basic care remains.

High energy prices on world markets have ensured greater macroeconomic stability, a budget surplus and improvements in living standards for most of the Russian population. However, despite an overall reduction in the poverty rate, there is a marked urban-rural split and rural populations have worse health and poorer access to health services than urban populations. The increase in budgetary resources available to policy-makers has led to a number of recent federal-level health programmes that have focused on the delivery of services and increasing funding for priority areas –— including primary care provision in rural areas. Nevertheless, public health spending in the Russian Federation remains relatively low given the resources available. It is also clear that, even with the current level of financing, the performance of the health system could be improved.

Provider payment mechanisms are the main obstacle to improving technical efficiency in the Russian health system, as most budget funding provided through local government is input based. For this reason, the most recent reforms as well as legislation in the pipeline seek to ensure that all health care funding is channeled through a strengthened MHI system with contracts for provider payments that use output-based measures.

Analysis and results

Since the turn of the century, the health status of the population of the Russian Federation has been improving, and average life expectancy has almost returned to the level it was in 1990 prior to the dissolution of the Soviet Union. The overall mortality rate has decreased by 4% and the mortality rate at working age has decreased for both men and women, by 15% and 7%, respectively. The biggest improvements have been seen in maternal and child health: infant mortality, under-5 mortality and maternity mortality rates have more than halved. However, despite these positive trends, indicators show that the health of the Russian population is considerably worse than the health of populations in western and central eastern Europe or in other G8 countries.

The efficiency of social spending in the Russian Federation, including health expenditure, has been assessed as poor because similar health outcomes in terms of mortality are observed in other countries that spend 30% to 40% less on health.

There is also much scope to improve the allocative efficiency of the Russian health system. Input data show that the Russian health system significantly favours inpatient care at the expense of primary care services. Resource usage indicators also point to low allocative efficiency. For example, the hospitalization rate is much higher than in other countries of the WHO European Region. This high rate of hospitalization, along with high rates of emergency care calls (frequently for patients with chronic disease complications), testifies to the low efficiency of primary care. Recent reform efforts have sought to strengthen primary care services, but there is no evidence yet that this policy has been successful.


In 2010, the new Law on Mandatory Health Insurance and the Law on the Legal Status of Public Facilities were adopted. The Law on Mandatory Health Insurance envisages mechanisms for transferring the financing system from its current dual-stream financing to a single-channelled system and aims to ensure the long-term financial sustainability of the MHI system. The Law on the Legal Status of Public Facilities aims to broaden the range of legal forms health providers can have to strengthen responsibilities for provider performance results and to grant providers more economic and managerial flexibility.

Further implementation of reforms will depend on the government’s ability to monitor the reform process, critically evaluate the achievement of goals and targets, and introduce changes when needed. Central to the success of future reforms will be the broad involvement of all the main stakeholders at all levels and efforts to gain the support of regional authorities and the medical community.

Implications and recommendations

After a decade in which there was little discussion about reforming the health system, the Russian Government has, over the past few years, started paying more attention to health issues. The government programme for the long-term and social development of the Russian Federation to the year 2020 recognizes health as a crucial factor for the country’s future development and put health system improvement as a policy priority. The programme sets ambitious targets to be achieved by 2020, including increasing average life expectancy to 75 years and increasing government expenditure on health to 5.2% of GDP (from 3.4% in 2008).

In 2009 the Ministry of Health approved the National Health Concept to the year 2020. The Concept sets ambitious targets to significantly increase life expectancy and cut mortality rates by strengthening health promotion activities and providing high-quality medical services. The Concept considers many aspects of the health system and how it functions. It envisages that the state guaranteed package of medical benefits free at the point of use will be specified and that the balance between guarantees and funds allocated for this purpose be found through a heavy reliance on medical standards as the basis for cost estimations. The Concept aims to improve allocative efficiency by strengthening primary care, optimizing secondary care and introducing a quality control system based on the implementation of unified national medical standards and procedures. Another priority area for the Ministry is to improve access to prescription pharmaceuticals for the whole population. Consequently, the Concept stipulates the introduction of mandatory drug insurance to cover the reimbursement of outpatient pharmaceutical costs.

The Concept pays a lot of attention to the improvement of personnel policies, suggesting a reallocation of functions between physicians and nurses and the improvement of training and continuous medical education systems. The Concept also suggests paths for the development of IT systems in health care. The Concept could be treated as a framework for future reforms to be followed by the government. 


Russian Federation – Health System Review. Health systems in transition, 2011