While Russia has made a remarkable progress in many respects since the economic crisis of the late 1990s, it will struggle to meet its full potential in the future without improving health conditions among its population and restructuring of its health system.
Over the period of 2003-2008, the Russian Ministry of Health and Social Development (MOHSD), with the World Bank support, launched a pilot project - the Health Reform Implementation Project (HRIP) - to infuse financial resources and technical assistance into two regions southeast 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. Policy and institutional instruments were developed to support the redesign of the regional health systems, 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.
The goal of these reforms, as noted by Patricio Marquez, World Bank Lead Specialist and Team Leader of the Project, was “to support efforts to deal with the fragmentation and poor quality of services, shift the balance of care provided from hospitals to outpatient services at the primary level, introduce evidence-based standards for the training of personnel and the delivery of medical care, and adopt measures to ensure continuity of funding and to create incentives for high quality and efficient services to better respond to the needs of the population.”
More people have access to general practitioners: from 13% to 65% in Chuvashia and from 3% to 30% in Voronezh
The results achieved in the two regions are promising and provide clear evidence that health reform, while technically and politically complex across the world, is indeed possible in the Russian Federation. 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 to approximately 65% in the Chuvash Republic in 2008, up from 13% in 2003, and to close to 30% in Voronezh in 2008, up from 3% in 2003.
Other 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. These reforms, coupled by innovative approaches to health services delivery, such as the establishment of day care centers for outpatient surgery, diagnostic and other services, helped to reduce unnecessary and costly 24-hour beds by 18% in the Chuvash Republic, and 24% in Voronezh over 2003-2008. The introduction of modern diagnostic and treatment technologies, and the streamlining of the delivery of health services, helped to reduce the average length of stay from in both regions below the average stay across Russia of 13.8 days.
Ambulance waiting time reduced from 21 minutes to 13.5 minutes in Chuvashia, and in Voronezh within 15 minutes
The improved response capacity of the emergency medical services is allowing the regional health systems to timely deal with heart attacks, strokes, road traffic injuries, and other conditions that require immediate care to prevent unnecessary deaths and lasting disabilities. With the replacement and modernization of the ambulance fleet, the establishment of a centralized ambulance dispatcher centers and improved communication systems between ambulances and health facilities, including the use of global positioning systems (GPS), and training of medical staff and paramedics in advance and basic life support systems, waiting times for an ambulance to arrive at the scene of a medical emergency were reduced in the Chuvash Republic from 20.9 minutes in 2006 to 13.5 minutes in 2008. Similarly, in Voronezh on average 83 percent of all emergency calls were responded to by the arrival of an emergency team within 15 minutes in 2008 (the average response time in Russia is 25 minutes).
The development of regional health accounts is helping monitor the financial flows within the health system, and the introduction of provider payment methods is encouraging better provider performance, particularly at the primary care level.
Quality assurance systems and about 500 standards and guidelines were developed to guide the efficient and appropriate use of new diagnostic equipment, and delivery of effective services. To sustain these reforms over the medium term, substantial investments were allocated for developing human resources in the health system as a whole. Both regions have introduced dedicated training programs 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 primary care facilities, continuing professional development programs have been introduced to update the knowledge and skill base of health personnel. 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.
Patient satisfaction increased in both pilot regions, and the reforms in the health system have contributed to improve health conditions as measured by several indicators.
“It is very convenient now. After the GP office has been opened, coming here is more convenient and pleasant. The doctors are very good and responsive. Everybody says our health care is better than the services in the city. We always used to go to the city which was difficult and far. And now everything is modern and more accessible,” comments Svetlana, mother of a small patient about the GP office in the rural area of Chuvash Republic.
The achievements in Chuvash Republic and Voronezh Oblast demonstrate that it is possible to restructure regional health systems to address the public health challenges faced by the Russian Federation. The experience in both regions provides much needed evidence to inform regional health system strengthening efforts in other regions of the country.
"The key to success under the HRIP was a convergence of leadership and partnerships - developing strong partnerships between all the players involved and developing a common understanding of what could be done to improve the delivery of health care,” concluded Mary Collins, Former Manager of WHO Health Policy and Stewardship Program in Russia and Resident Advisor for the Canadian/Chuvash Health Reform Project.