- Email: [email protected]
Intersectoral problems in the Russian organisation of public health
Health Policy 73 (2005) 285–293
Intersectoral problems in the Russian organisation of public health Runo Axelsson∗ , Susanna Bihari-Axelsson Health Management, Nordic School of Public Health, Nya Varvet, P.O. Box 12133, SE-402 42 Gothenburg, Sweden
Abstract In spite of the ongoing transition of the Russian society, there is still a traditional view of public health, which is based to a great extent on the ideals and priorities of the Soviet period. Public health activities are regarded mainly as a responsibility of the health sector. There are, however, important public health activities going on also in other sectors of the society, for example, in the educational sector and the local communities, but also in the social insurance system. There is an important Russian tradition of prophylactic treatment in sanatoriums and health resorts, which is financed to a large extent by the social insurance. Based on three qualitative empirical studies, this article describes the organisation of public health in the Russian Federation and analyses the problems of intersectoral co-ordination and collaboration within this organisation. The analysis is focusing on the relations between the health sector and the social insurance system, which are not so well known outside the country. The results of this analysis show a fragmented organisation with a serious lack of co-ordination, but also a limited collaboration between the different sectors involved in public health. On the basis of these results, there is a discussion of how intersectoral collaboration could be improved in the Russian organisation of public health. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Public health; Intersectoral; Co-ordination; Collaboration
1. Introduction Public health has often been described as an organisational phenomenon. In 1988, public health was defined by a British government committee as “the science and art of preventing disease, prolonging life, and promoting health through organised community efforts” [1]. More recently, the concept of public health has been broadened to include not only prevention and health promotion but also medical treatment and rehabilitation. The mutual benefits of curative and ∗
Corresponding author. Tel.: +46 31 693924; fax: +46 31 691777. E-mail address: [email protected] (R. Axelsson).
preventive work have been increasingly recognised [2]. With such a wide range of activities, the organisational aspects have become even more important. Public health involves many different actors, not only from the health sector but also from other sectors of the society, such as social services, education, environmental protection, etc. These actors usually include government agencies on different levels of the society. There may also be non-government organisations, community groups and private enterprises involved in public health activities. The main organisational problem is to bring all of these different actors together in a common pursuit of public health. In the Ottawa Charter for Health Promotion [3], it was pointed out that there
0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2004.11.020
286
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
is a need for “intersectoral” co-ordination and collaboration in public health. It is difficult to co-ordinate different actors within the health sector, but it is even more difficult to coordinate actors from different sectors of the society. This requires a more or less voluntary collaboration between different organisations. According to organisation theory, such interorganisational relations are more “loosely coupled” than intraorganisational relations, since the different organisations may not be part of a common hierarchy [4]. Instead, interorganisational relationships are often described in terms of networks, partnerships, coalitions or strategic alliances of organisations, or as an “ecology” of organisations [5]. This terminology is also reflected in the literature of public health, where intersectoral collaboration has been described as networks of actors, healthy alliances or “socio-ecological” approaches to prevention and health promotion [6]. In many European countries there has been a development of intersectoral co-ordination and collaboration in public health since the publication of the Ottawa Charter [7]. In other countries, however, this development has been much slower. In the Russian Federation, there is still a narrow view of public health prevailing, and the term is reserved mainly for activities within the health sector [8]. The Russian health sector is a huge and complex system for provision and financing of health services to the population. It is controlled by the Ministry of Health and divided into federal, regional and municipal levels. In addition, there are also parallel systems providing and financing separate health services for employees of other sectors, like defence, railways and public enterprises [9]. Both the health sector and the parallel health systems are dealing with preventive activities as well as medical care. However, there is preventive work going on also in other sectors of the Russian society, for example, in the educational sector and the local communities. There are also important preventive activities in the social insurance system. According to a tradition from the Soviet period, the social insurance is financing different activities for health improvement of workers and their family members in sanatoriums, health resorts and children’s summer camps. These preventive activities have been found to have beneficial effects on the health of the workers and their families [10]. They
are not co-ordinated, however, with the preventive work within the health sector, the parallel health systems and the other sectors involved in public health. In fact, there seems to be very little co-ordination and collaboration between different sectors in the Russian society [11]. It is not unusual to have a lack of co-ordination between the health sector and other sectors involved in public health. Many countries have problems with intersectoral co-ordination and collaboration [7], but the extent of the co-ordination problems in the Russian society seems to be quite unusual. Preventive activities are fragmented, both within the health sector and between this sector and other sectors of the society. This fragmentation is particularly problematic considering the health status of the population [8]. According to available statistical data, the health of the Russian population is deteriorating. During the last 15 years the average life expectancy for men has been declining from 64.9 to 57.6 years [12], and there is an increasing mortality from non-communicable diseases [13]. At the same time, there is also a difficult economic situation in the country and the real public spending on health care fell by nearly one-third between 1990 and 2000 [14]. As a consequence, the health sector is seriously under-financed, and there are not enough public resources to fulfil the state guarantees on health care. The deficit is bridged by unofficial and “private” payments of different kinds [8]. Against this background, it would be important to develop the organisation of public health and try to mobilise all possible resources for health care, disease prevention and health promotion in the Russian Federation. This means that there is a great need for intersectoral co-ordination and collaboration. The Federal Government has taken some initiatives to co-ordinate the health sector and the parallel health systems of other sectors, but these initiatives have mainly focused on the use of different health care facilities. In 1997, the government adopted a strategy for development of public health, which also contained some proposals for improving the co-ordination and collaboration between the health sector and other sectors involved in prevention and health promotion [9]. So far, however, the implementation of this strategy has been problematic and it has remained largely on paper. The purpose of this article is to describe the organisation of public health in the Russian Federation and to analyse the problems of intersectoral co-ordination and collaboration. After a short methodological introduc-
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
tion, there will be a description of the different actors involved in public health activities and the roles they are playing in the organisation of public health. There will be a special emphasis on the role of the sanatoriums and health resorts, which is not so well known outside the country. Then there will be a presentation of different problems of co-ordination and collaboration, focusing on the relationships between the health sector and the social insurance system, and finally a discussion of how the collaboration between these and other sectors involved in public health could be improved.
2. Methods This article is based on empirical data collected 1999-2000 in connection with three different projects in the Russian Federation. Two of these projects, one on preventive health care and one on the governance of social security, were financed by the European Commission, while a third project on health promotion was financed by the Stockholm County Council. The data were collected through a total of 28 interviews, following a strategic sample of officials and professional staff from different sectors of the society involved in public health activities: • Officials in the federal and the territorial health insurance funds, the Ministry of Health, different levels of the social insurance fund, and the Ministry of Labour. • Officials and medical staff of four sanatoriums and two children’s summer camps in five regions: Moscow city, the Moscow region, the Vladimir region, the Leningradsky region and the Astrakhan region. • Teachers and medical staff working with disease prevention and health promotion among teenagers in St Petersburg. These interview persons were chosen to represent a wide spectrum of knowledge, information and opinions. Among them were survivors from the old system as well as new technocrats. The interviews were made with an interview guide focusing on the roles and tasks of different actors in the Russian system of public health, their knowledge about each other, and their contacts, communication and co-operation. The interview guide served as a checklist to cover as many aspects
287
of co-ordination and collaboration as possible. The interviews were made by both of the authors, who were also involved in the projects mentioned above, but there was no conflict of interests in relation to these projects and therefore no risk of reporting bias. The interview persons were guaranteed confidentiality in answering the questions, and they agreed that their answers could be used in an anonymous way. All the answers were recorded and processed in accordance with qualitative data analysis, which means that they were transcribed, interpreted and analysed with respect to their content [15]. This process had to be repeated several times because of translation problems. The results were then compiled, presented and discussed with some of the interview persons, who were prepared to give a feedback on the validity of the interpretations and the content analysis [16]. Some of the interviews will be quoted in the text, but they will be presented in an anonymous form in order to protect the interview persons. The quotations have been chosen to illustrate the main points of the interviews and also to convey some of the flavour of the arguments and expressions of the interview persons. The interviews were supplemented by studies of official statistics and documents like federal laws, regulations and instructions of the different institutions involved. There were also studies of unpublished research and expert reports from the two EU-projects, “Preventive Health Care Systems” (EDRUS 9601) and “Governance of Social Security” (EDRUS 9605). The following presentation will not explicitly refer to these statistics, documents and reports, as such references would burden the text unnecessarily. Instead, they have been used mainly as background information for the interpretation and presentation of the interview results.
3. Results 3.1. The Russian organisation of public health As an important part of the transition of the Russian society, the previous Soviet system of health was during 1991–1993 replaced by a system with two main parts, health authorities and health insurance funds. The whole system is under the auspices of the federal Ministry of Health and usually referred to as the Ministry of Health system. The health authorities belong to
288
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
the governments on the regional (oblast) and municipal (rayon) levels of the society, providing health services to the population in hospitals and polyclinics [9]. The health insurance is organised in a compulsory system covering the whole population and administered by a federal health insurance fund and 89 territorial funds on the regional level. These funds are financed by insurance contributions paid by public and private enterprises and institutions. They are used mainly for financing the health services provided by the regional and municipal health authorities. The contracting of services is done by independent insurance companies and local branches of the territorial health insurance funds [11]. Beside the health authorities and the health insurance funds there are also parallel health systems within the Ministries of Defence, Railways, Interior and many others for provision of health services exclusively for their respective employees and their families. This is a heritage from the Soviet period. These health systems have their own networks of polyclinics and inpatient facilities. They are financed by the different ministries from the federal budget, but also from regional budgets and territorial health insurance funds on a contractual basis. There are also similar health systems within large public enterprises [9]. According to the interviews, there are growing differences in the provision of health services across the country, depending on local needs and circumstances. Since the dissolution of the Soviet Union there has been an increasing decentralisation of responsibilities from the federal level to the regional and municipal levels. There is a guaranteed package programme of health care, adopted by the federal government, which should be provided free of charge by the regions, but the regional and municipal authorities can also finance special programmes adapted to the needs of the local population. The guaranteed package programme contains primary health care and most health services provided by the hospitals and the polyclinics. Ambulance services are covered, as well as the treatment of “social dangers,” such as tuberculosis, psychiatric diseases, sexually transmitted diseases, drug abuse, etc. Both the health authorities and the health insurance funds have retained a traditional orientation towards curative medical services, with a bias towards in-patient care in hospitals, while preventive activities have been given a much lower priority. The health authorities are
allocating most of their resources to medical treatment, and the health insurance funds are mainly paying for hospitalisation and visits to doctors. Very limited resources are spent on prevention and health promotion [8]. The health insurance is financing health examinations of children and some vaccination programmes, while the health authorities are financing programmes for prevention of communicable diseases. According to some of the interview persons, these programmes are not very useful. “Both the health authorities and the health insurance funds are run by physicians, and their approach to prevention is to start from diseases. Prevention is understood as screening for separate diseases.” Most of the activities related to disease prevention and health protection are controlled and financed directly by the federal Ministry of Health. In the ministry, there is a Sanitary and Epidemiological Department, which is responsible for prevention of communicable diseases and environmental problems like air and water pollution. To perform these functions, the department has a number of sanitary and epidemiological centres in each region controlling the quality of air, water, food, etc. In addition, each hospital must report all infectious diseases to the regional centres. This is the so-called San-Epid system, which is another heritage from the Soviet period. The system performed an important role in disease control during this period, but it has not been able to adapt to changing circumstances. In the words of one of the interview persons, “it is a control structure, based on a narrow laboratory approach to prevention and focusing on traditional hygiene.” There are also a number of research institutes belonging to the Russian Academy of Medical Science that are dealing with prevention and health promotion, for example, the Institute of Preventive Medicine and the Institute of Health Promotion. These institutes are not only conducting scientific research, but they are also actively involved in preventive activities. The Institute of Preventive Medicine is working with screening and vaccination programmes, for example, screening for tuberculosis and vaccination against polio, together with municipal departments for disease prevention. The Institute of Health Promotion is working with health information and education together with regional centres for medical prevention. These centres are not so active, however, and they have very limited resources. Some of the interview persons were also
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
critical of their work. “They are mostly run by retired physicians, old ladies who are not so interested in the development of the field, only in producing brochures.” Beside the activities of the health sector and the academy of medical science, there are preventive activities going on also in other sectors of the society, although they are not formally recognised as parts of the Russian organisation of public health. One of the most important sectors is the social insurance system. Based on a tradition from the Soviet period, the social insurance is financing prophylactic treatment and rehabilitation of workers and their families in sanatoriums, health resorts and children’s summer camps. These institutions are run by trade unions, local authorities or private entrepreneurs, but their activities are financed to a large degree by the social insurance. This is not only for historical reasons. As one of the interview persons explained, “the social insurance system regards these activities as investments in the health of the working population, which are supposed to pay off in the form of a reduced need for sickness benefits.” The Russian system of social insurance is administered by the social insurance fund and controlled by the Ministry of Labour. The social insurance fund is a centralised federal organisation with regional and industrial branch divisions. Like the health insurance, the social insurance is financed by insurance contributions from public and private enterprises and institutions, but it is covering only the working population. Most of the contributions are spent on sickness cash benefits, but the fund is also paying a number of other benefits and allowances. Around 25% of the total resources are spent on buying vouchers to sanatoriums, health resorts and children’s summer camps [11]. These vouchers are distributed for a reduced price to workers and their family members by social insurance committees in the enterprises. The distribution and the price of the vouchers are decided on the basis of medical prescriptions and the social situation of the workers. The sanatoriums and health resorts offer prophylactic treatments for a broad spectrum of diseases. The children’s summer camps have no medical facilities, but they offer prophylactic and recreational activities to improve the health status of the children. According to the interviews, these institutions and the activities they offer are beneficial, both for the people and for the national economy. There is also some statistical evidence to support this claim [10]. During the last years,
289
however, the financing of these activities by the social insurance system has been questioned. Some of the interview persons were regretting this development. “If the social insurance financing is reduced, the sanatoriums and health resorts have to become more and more commercial in order to survive. This means that the people who need them most will not be able to afford their services.” Beside the activities of the health sector, the academy of medical science and the social insurance system, there are also other sectors involved in the Russian organisation of public health. The educational sector has an important role in connection with health information and health education. There are, for example, campaigns in the schools for physical exercise and a healthy life style. There are also preventive activities in many enterprises, for example, medical examinations and prophylactic treatments for the employees and their families. Finally, there are a number of non-governmental organisations working with prevention and health promotion. These organisations are voluntary and have very little resources. They are mainly concentrating on certain population groups, such as handicapped children or elderly. There are also voluntary organisations working together with the church and the social authorities to prevent drug abuse. 3.2. Problems of co-ordination and collaboration The Government of the Russian Federation is responsible for the development of all the different sectors of the society. Within the federal government, one of the vice-premiers is responsible for all the developments within the so-called “improductive” sectors of the society, including health, education and social security. There is also an inter-ministerial committee, headed by this vice-premier, which is dealing with the co-ordination of activities between these sectors, including the activities of public health [11]. There have been a number of policy initiatives in this committee to co-ordinate the preventive activities of the health sector and the social insurance system. According to the interviews, however, these initiatives have not been very effective. As one of the interview persons put it, “the co-ordinating efforts on this level are creating a lot of paperwork, but very few concrete results.” There is not only a lack of co-ordination between the different sectors involved in public health, but also
290
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
very little co-ordination of the different activities within the health sector. As mentioned before, the preventive activities and the curative services are organised as two different systems. Most of the preventive activities are controlled directly by the Ministry of Health or the Academy of Medical Science, while the health services are controlled by the regional and municipal health authorities. Within the municipalities there have been some efforts to integrate the departments for disease prevention into the polyclinics, but the primary health care has shown little interest in preventive activities. Thus, in addition to the lack of co-ordination there is a limited collaboration between the different parts of the health sector. In a similar way, there is a limited intersectoral collaboration in addition to the lack of coordination between the health sector and other sectors involved in public health. On the federal level, the intersectoral collaboration is restricted to some international projects, for example, “Health Promoting Schools,” where the Ministry of Health is collaborating with the Ministry of Education. There is also some collaboration on the regional and municipal levels between the health sector and the educational sector. In St Petersburg, for example, the health authorities are working together with the school authorities in a project to prevent abortions and sexually transmitted diseases among teenagers. In Vologda, public resources have been collected from different sectors for prevention of non-communicable diseases. There are also non-governmental organisations and community groups involved in preventive activities together with the church and the social authorities in some regions and municipalities. According to the interviews, however, these examples are exceptional cases. “In general, health promotion and disease prevention on the regional and municipal levels is poorly financed, inadequately organised and badly co-ordinated.” There are few contacts and very little collaboration between the health sector and the social insurance system. Moreover, the relations between the two sectors seem to be quite problematic, particularly the relations between the health insurance funds and the social insurance fund. As one of the interview persons pointed out, “there is a competition for resources between the different funds, and both of them think that they are disadvantaged and could use the resources in a better way than the other.” There are also issues where the funds have conflicts of interests, for example, the rela-
tion between inpatient and outpatient care. The health insurance funds want to reduce the length of stay in hospitals in order to reduce the health care costs. The social insurance fund wants the patients to stay in the hospitals as long as possible in order to prevent aggravation of diseases and increased costs for sickness benefits. Another issue where there are conflicts of interests between the health insurance funds and the social insurance fund concerns the use of the sanatoriums and the health resorts. The social insurance is financing prophylactic treatments in these facilities in order to improve the health of the working population and reduce the needs for sickness benefits. The health insurance funds, on the other side, would like to use the sanatoriums instead for post-operative medical treatment and rehabilitation in order to reduce the need for hospitalisation. For this purpose, the health insurance funds would also like to take over the resources that the social insurance fund is spending on the prophylactic treatments. According to one of the interview persons from the federal health insurance fund, “the places in the sanatoriums should be used for people in real need of care instead of people who have only prophylactic needs.” There have been some efforts recently to improve the relations between the social insurance fund and the health insurance funds. They have had some collaboration in connection with rehabilitation after heart attacks and some major surgeries. The social insurance fund has provided vouchers for sanatorium treatment, which has been paid partly by the health insurance funds. There has also been a discussion about extending the compulsory health insurance to include also prophylactic treatments. The officials of the federal health insurance fund have been against such an extension of the insurance, however, since they think that it should not be used to finance prophylactic activities. According to one of the interview persons from the social insurance fund, “the federal health insurance fund does not recognise the value of the prophylactic treatments, but it benefits from the effects of these treatments on the health status of the population.” 4. Discussion The results of the interviews and the documentary studies show that there is a fragmented organisation of
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
public health in the Russian Federation. There are many different actors on the federal, regional and municipal levels of the health sector and in the parallel health systems for the military, the railway workers, etc. There are also important preventive activities going on outside the health sector, particularly within the social insurance system, where prophylactic treatment and rehabilitation is performed together with trade unions, local authorities and private entrepreneurs in sanatoriums, health resorts and children’s summer camps. There are also other sectors involved in public health, although their activities are on a much smaller scale. There are some preventive activities within the educational sector, particularly in the school system, and also in the enterprises, the social sector and the church. These activities are mainly on the regional and municipal levels of the society. There are also non-governmental organisations and community groups involved in public health activities on these levels. Together all of these actors, from different sectors and different levels of the society constitute the Russian organisation of public health. This is not an organisation in the usual sense of the word, but rather a “multi-organisation” consisting of many different interorganisational relations [17]. There is obviously a lack of co-ordination between the different actors in this organisation. The efforts of the federal government to co-ordinate the different sectors involved in public health are perceived not to be very effective. In a similar way, there is also a lack of co-ordination between the different actors within the health sector. The curative and the preventive parts of the health care system are working quite independent of each other and there have been no serious efforts to co-ordinate their activities. This lack of co-ordination in the Russian organisation of public health is not surprising, since it is very difficult to co-ordinate complex interorganisational systems in the traditional hierarchical way [18,19]. According to organisation theory, the absence of an effective hierarchical co-ordination may instead be compensated by a voluntary collaboration between the different actors. Collaboration means a more informal bottom-up approach in contrast to the traditional top-down approach of co-ordination [20]. There is, however, also a lack of collaboration between the different actors in the Russian organisation of public health. There is a limited collaboration be-
291
tween the curative and preventive parts of the health care system. There are some examples of intersectoral collaboration on the regional and the municipal levels of the society, but they are regarded as exceptional cases. In general, therefore, it seems to be very difficult to collaborate across the organisational boundaries of the Russian society, both within the health sector and between the different sectors involved in public health activities. The lack of intersectoral collaboration between the health sector and the social insurance system is particularly problematic. The health insurance funds and the social insurance fund show a territorial behaviour typical of a “tribal culture” [21]. This is probably another heritage from the Soviet period. In accordance with this culture, the different funds are defending their territories and trying to transfer costs to each other. There is also a competition for resources between the funds and a struggle to control certain institutions, like the sanatoriums and health resorts. In addition, there seems to be some “ideological” differences between representatives of the different funds, for example, in their view of prophylactic activities. The question is how intersectoral collaboration can be improved in the Russian organisation of public health, not only between the health sector and the social insurance system, but also between these sectors and the other sectors involved in public health. First of all, it would be important to improve the differentiation of roles and tasks between the different actors engaged in public health activities. They all have their separate responsibilities according to the legislation of the Russian Federation, but their joint responsibilities for public health are not regulated. A clear understanding of the roles and tasks of the different sectors may reduce many of the present problems of co-ordination and collaboration. This must be clarified by the federal government and by the actors themselves in a process of negotiation. Moreover, these roles and tasks cannot be defined once and for all, but have to be continuously discussed and reconsidered [22]. Secondly, it would be important to improve the integration between the different actors in the organisation of public health. One way would be to establish a national authority to initiate and support intersectoral collaboration in public health. However, with the size and traditions of the Russian society, there is a risk that such an authority would develop into a huge bureau-
292
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
cracy, a “co-ocracy” [23]. Another way would be to encourage the different actors to form networks, partnerships, coalitions or alliances in different areas of public health. Experiences from other countries may serve as an inspiration in this connection [24,25]. Another way would be to establish special liaison committees on the regional and municipal levels of the Russian society. These committees could serve as forums or arenas for joint intersectoral decision-making on issues of public health. In these committees, it would be important to involve also non-government organisations and groups of empowered users, patients and other beneficiaries, who may be able to counteract the tribalism of the different actors and provide a more holistic view of public health [26]. The collaboration between the different actors in the organisation of public health is not an end in itself, however, but only a means to mobilise all the possible resources for public health activities and to use them in the best possible way. This is particularly important in the Russian Federation, considering the difficult economic situation and the bad health status of the population. Therefore, the intersectoral collaboration must be continuously reviewed and evaluated, both by the actors themselves and by the people who are subject to their activities. It would also be important to have systematic evaluations by independent agencies or research institutes in order to discover intersectoral problems and to promote organisational learning [27,28]. Such a process of continuous and systematic evaluation may lead to a development of intersectoral collaboration in the Russian organisation of public health.
5. Concluding remarks The analysis of the Russian organisation of public health has identified a lack of intersectoral co-ordination and collaboration, which is a serious problem considering the bad health status of the population and the need to mobilise all the possible health resources. Since an effective hierarchical co-ordination is difficult to achieve in a complex interorganisational system like this, the discussion has focused on different ways to improve the voluntary collaboration between the different actors involved in the organisation of public health.
Some of the improvements would however require radical cultural changes in the Russian society. As mentioned before, it would be necessary to change the culture of tribalism, which has been so strong in the state administration since the Soviet period. In addition to that, it would also be necessary to change the attitudes of the different institutions towards their users, patients and other beneficiaries. There is still a very authoritarian culture prevailing in most public institutions, and there is no tradition to listen to and consider the opinions of the beneficiaries. Finally, a continuous review and evaluation of intersectoral collaboration would require a culture of openness that does not exist among the actors involved in public health. Thus, with all the cultural changes required, it may take a long time to improve the intersectoral collaboration in the Russian organisation of public health. Since 2000, when most of the empirical data were collected, there have been some changes in the federal government, the tax system and the organisation of the ministries involved in public health. For example, the parts of the Ministry of Labour dealing with social development have been merged with the Ministry of Health. There have also been some recent reform proposals in the field of public health, linked to the WHO principles of health for all [29]. However, the implementation of these changes is slow and most of the intersectoral problems discussed in this article still remain. References [1] Acheson ED. Report of the committee of enquiry into the future development of the public health function. In: Public health in England. London: HMSO; 1988. [2] Frenk J. The new public health: reflections for the debate. In: The crisis of public health. Washington, DC: PanAmerican Health Organization; 1992. p. 68–85. [3] Ottawa Charter for Health Promotion. Health Promotion 1986;1:iii–v. [4] Weick KE. Sensemaking in organizations. London: Sage; 1995. [5] Hannan MF, Freeman J. Organizational ecology. Cambridge, MA: Harvard University Press; 1989. [6] Davies JK, Macdonald G, editors. Quality, evidence and effectiveness in health promotion. London: Routledge; 1998. [7] Saltman RB, Figueras J. European health care reform: analysis of current strategies. Copenhagen: WHO Regional Publications; 1997. [8] Tkatchenko E, McKee M, Tsouros AD. Public health in Russia: the view from the inside. Health Policy and Planning 2000;15:164–9.
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293 [9] European Observatory on Health Care Systems. Health Care Systems in Transition: Russian Federation. Copenhagen: WHO Regional Office for Europe; 2003. [10] Bihari-Axelsson S, Axelsson R. The role and effects of sanatoriums and health resorts in the Russian Federation. Health Policy 2002;59:25–36. [11] Axelsson R. Institutional developments in the Russian system of social security: organizational and interorganizational aspects. Social Policy & Administration 2002;36:142– 55. [12] Field MG. The health and demographic crisis in post-Soviet Russia: a two-phase development. In: Field MG, Twigg JL, editors. Russia’s torn safety net. New York: St. Martin’s Press; 2000. [13] WHO. Health for all. Copenhagen: WHO Database; 2002. [14] OECD. The social crisis in the Russian Federation. Paris: OECD; 2001. [15] Taylor SJ, Bogdan R. An introduction to qualitative research methods. 3rd ed. New York: John Wiley & Sons; 1998. [16] Bowling A. Research methods in health. Buckingham: Open University Press; 1997. [17] Hjern B. Illegitimate democracy: a case for multiorganizational policy analysis. Policy Currents 1992;2:1–5. [18] Gray B. Conditions facilitating interorganizational collaboration. Human Relations 1985;38:911–36. [19] Alter C, Hage J. Organizations working together. London: Sage; 1993.
293
[20] Sanderson I. Effective inter-sectoral coaboration: the theoretical issues. Leeds: Health Education Unit, Leeds Metropolitan University; 1990. [21] Bate P. Changing the culture of a hospital: from hierarchy to networked community. Public Administration Review 2000;78:485–512. [22] Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. The Millbank Quarterly 1999;77:77–110. [23] Allen JE. Co-ocracy: a proposal for classifying coordinating organizations. The Bureaucrat 1975;4:163–80. [24] El Ansari W, Phillips CJ, Hammick M. Collaboration and partnerships: developing the evidence base. Health and Social Care in the Community 2001;9:215–27. [25] Mitchell SM, Shortell SM. The governance and management of effective community health partnerships: a typology for research policy and practice. The Millbank Quarterly 2000;78:241–89. [26] Barnes M, Walker A. Consumerism versus empowerment: a principled approach to the involvement of older service users. Policy and Politics 1996;24:375–93. [27] Axelsson R. Towards an evidence based health care management. International Journal of Health Planning and Management 1998;13:307–17. [28] Øvretveit J. Action evaluation of health programmes and changes. Oxford: Radcliffe Medical Press; 2002. [29] WHO. Health for all in the 21st century. Geneva: WHO; 1998.
Intersectoral problems in the Russian organisation of public health Runo Axelsson∗ , Susanna Bihari-Axelsson Health Management, Nordic School of Public Health, Nya Varvet, P.O. Box 12133, SE-402 42 Gothenburg, Sweden
Abstract In spite of the ongoing transition of the Russian society, there is still a traditional view of public health, which is based to a great extent on the ideals and priorities of the Soviet period. Public health activities are regarded mainly as a responsibility of the health sector. There are, however, important public health activities going on also in other sectors of the society, for example, in the educational sector and the local communities, but also in the social insurance system. There is an important Russian tradition of prophylactic treatment in sanatoriums and health resorts, which is financed to a large extent by the social insurance. Based on three qualitative empirical studies, this article describes the organisation of public health in the Russian Federation and analyses the problems of intersectoral co-ordination and collaboration within this organisation. The analysis is focusing on the relations between the health sector and the social insurance system, which are not so well known outside the country. The results of this analysis show a fragmented organisation with a serious lack of co-ordination, but also a limited collaboration between the different sectors involved in public health. On the basis of these results, there is a discussion of how intersectoral collaboration could be improved in the Russian organisation of public health. © 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Public health; Intersectoral; Co-ordination; Collaboration
1. Introduction Public health has often been described as an organisational phenomenon. In 1988, public health was defined by a British government committee as “the science and art of preventing disease, prolonging life, and promoting health through organised community efforts” [1]. More recently, the concept of public health has been broadened to include not only prevention and health promotion but also medical treatment and rehabilitation. The mutual benefits of curative and ∗
Corresponding author. Tel.: +46 31 693924; fax: +46 31 691777. E-mail address: [email protected] (R. Axelsson).
preventive work have been increasingly recognised [2]. With such a wide range of activities, the organisational aspects have become even more important. Public health involves many different actors, not only from the health sector but also from other sectors of the society, such as social services, education, environmental protection, etc. These actors usually include government agencies on different levels of the society. There may also be non-government organisations, community groups and private enterprises involved in public health activities. The main organisational problem is to bring all of these different actors together in a common pursuit of public health. In the Ottawa Charter for Health Promotion [3], it was pointed out that there
0168-8510/$ – see front matter © 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2004.11.020
286
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
is a need for “intersectoral” co-ordination and collaboration in public health. It is difficult to co-ordinate different actors within the health sector, but it is even more difficult to coordinate actors from different sectors of the society. This requires a more or less voluntary collaboration between different organisations. According to organisation theory, such interorganisational relations are more “loosely coupled” than intraorganisational relations, since the different organisations may not be part of a common hierarchy [4]. Instead, interorganisational relationships are often described in terms of networks, partnerships, coalitions or strategic alliances of organisations, or as an “ecology” of organisations [5]. This terminology is also reflected in the literature of public health, where intersectoral collaboration has been described as networks of actors, healthy alliances or “socio-ecological” approaches to prevention and health promotion [6]. In many European countries there has been a development of intersectoral co-ordination and collaboration in public health since the publication of the Ottawa Charter [7]. In other countries, however, this development has been much slower. In the Russian Federation, there is still a narrow view of public health prevailing, and the term is reserved mainly for activities within the health sector [8]. The Russian health sector is a huge and complex system for provision and financing of health services to the population. It is controlled by the Ministry of Health and divided into federal, regional and municipal levels. In addition, there are also parallel systems providing and financing separate health services for employees of other sectors, like defence, railways and public enterprises [9]. Both the health sector and the parallel health systems are dealing with preventive activities as well as medical care. However, there is preventive work going on also in other sectors of the Russian society, for example, in the educational sector and the local communities. There are also important preventive activities in the social insurance system. According to a tradition from the Soviet period, the social insurance is financing different activities for health improvement of workers and their family members in sanatoriums, health resorts and children’s summer camps. These preventive activities have been found to have beneficial effects on the health of the workers and their families [10]. They
are not co-ordinated, however, with the preventive work within the health sector, the parallel health systems and the other sectors involved in public health. In fact, there seems to be very little co-ordination and collaboration between different sectors in the Russian society [11]. It is not unusual to have a lack of co-ordination between the health sector and other sectors involved in public health. Many countries have problems with intersectoral co-ordination and collaboration [7], but the extent of the co-ordination problems in the Russian society seems to be quite unusual. Preventive activities are fragmented, both within the health sector and between this sector and other sectors of the society. This fragmentation is particularly problematic considering the health status of the population [8]. According to available statistical data, the health of the Russian population is deteriorating. During the last 15 years the average life expectancy for men has been declining from 64.9 to 57.6 years [12], and there is an increasing mortality from non-communicable diseases [13]. At the same time, there is also a difficult economic situation in the country and the real public spending on health care fell by nearly one-third between 1990 and 2000 [14]. As a consequence, the health sector is seriously under-financed, and there are not enough public resources to fulfil the state guarantees on health care. The deficit is bridged by unofficial and “private” payments of different kinds [8]. Against this background, it would be important to develop the organisation of public health and try to mobilise all possible resources for health care, disease prevention and health promotion in the Russian Federation. This means that there is a great need for intersectoral co-ordination and collaboration. The Federal Government has taken some initiatives to co-ordinate the health sector and the parallel health systems of other sectors, but these initiatives have mainly focused on the use of different health care facilities. In 1997, the government adopted a strategy for development of public health, which also contained some proposals for improving the co-ordination and collaboration between the health sector and other sectors involved in prevention and health promotion [9]. So far, however, the implementation of this strategy has been problematic and it has remained largely on paper. The purpose of this article is to describe the organisation of public health in the Russian Federation and to analyse the problems of intersectoral co-ordination and collaboration. After a short methodological introduc-
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
tion, there will be a description of the different actors involved in public health activities and the roles they are playing in the organisation of public health. There will be a special emphasis on the role of the sanatoriums and health resorts, which is not so well known outside the country. Then there will be a presentation of different problems of co-ordination and collaboration, focusing on the relationships between the health sector and the social insurance system, and finally a discussion of how the collaboration between these and other sectors involved in public health could be improved.
2. Methods This article is based on empirical data collected 1999-2000 in connection with three different projects in the Russian Federation. Two of these projects, one on preventive health care and one on the governance of social security, were financed by the European Commission, while a third project on health promotion was financed by the Stockholm County Council. The data were collected through a total of 28 interviews, following a strategic sample of officials and professional staff from different sectors of the society involved in public health activities: • Officials in the federal and the territorial health insurance funds, the Ministry of Health, different levels of the social insurance fund, and the Ministry of Labour. • Officials and medical staff of four sanatoriums and two children’s summer camps in five regions: Moscow city, the Moscow region, the Vladimir region, the Leningradsky region and the Astrakhan region. • Teachers and medical staff working with disease prevention and health promotion among teenagers in St Petersburg. These interview persons were chosen to represent a wide spectrum of knowledge, information and opinions. Among them were survivors from the old system as well as new technocrats. The interviews were made with an interview guide focusing on the roles and tasks of different actors in the Russian system of public health, their knowledge about each other, and their contacts, communication and co-operation. The interview guide served as a checklist to cover as many aspects
287
of co-ordination and collaboration as possible. The interviews were made by both of the authors, who were also involved in the projects mentioned above, but there was no conflict of interests in relation to these projects and therefore no risk of reporting bias. The interview persons were guaranteed confidentiality in answering the questions, and they agreed that their answers could be used in an anonymous way. All the answers were recorded and processed in accordance with qualitative data analysis, which means that they were transcribed, interpreted and analysed with respect to their content [15]. This process had to be repeated several times because of translation problems. The results were then compiled, presented and discussed with some of the interview persons, who were prepared to give a feedback on the validity of the interpretations and the content analysis [16]. Some of the interviews will be quoted in the text, but they will be presented in an anonymous form in order to protect the interview persons. The quotations have been chosen to illustrate the main points of the interviews and also to convey some of the flavour of the arguments and expressions of the interview persons. The interviews were supplemented by studies of official statistics and documents like federal laws, regulations and instructions of the different institutions involved. There were also studies of unpublished research and expert reports from the two EU-projects, “Preventive Health Care Systems” (EDRUS 9601) and “Governance of Social Security” (EDRUS 9605). The following presentation will not explicitly refer to these statistics, documents and reports, as such references would burden the text unnecessarily. Instead, they have been used mainly as background information for the interpretation and presentation of the interview results.
3. Results 3.1. The Russian organisation of public health As an important part of the transition of the Russian society, the previous Soviet system of health was during 1991–1993 replaced by a system with two main parts, health authorities and health insurance funds. The whole system is under the auspices of the federal Ministry of Health and usually referred to as the Ministry of Health system. The health authorities belong to
288
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
the governments on the regional (oblast) and municipal (rayon) levels of the society, providing health services to the population in hospitals and polyclinics [9]. The health insurance is organised in a compulsory system covering the whole population and administered by a federal health insurance fund and 89 territorial funds on the regional level. These funds are financed by insurance contributions paid by public and private enterprises and institutions. They are used mainly for financing the health services provided by the regional and municipal health authorities. The contracting of services is done by independent insurance companies and local branches of the territorial health insurance funds [11]. Beside the health authorities and the health insurance funds there are also parallel health systems within the Ministries of Defence, Railways, Interior and many others for provision of health services exclusively for their respective employees and their families. This is a heritage from the Soviet period. These health systems have their own networks of polyclinics and inpatient facilities. They are financed by the different ministries from the federal budget, but also from regional budgets and territorial health insurance funds on a contractual basis. There are also similar health systems within large public enterprises [9]. According to the interviews, there are growing differences in the provision of health services across the country, depending on local needs and circumstances. Since the dissolution of the Soviet Union there has been an increasing decentralisation of responsibilities from the federal level to the regional and municipal levels. There is a guaranteed package programme of health care, adopted by the federal government, which should be provided free of charge by the regions, but the regional and municipal authorities can also finance special programmes adapted to the needs of the local population. The guaranteed package programme contains primary health care and most health services provided by the hospitals and the polyclinics. Ambulance services are covered, as well as the treatment of “social dangers,” such as tuberculosis, psychiatric diseases, sexually transmitted diseases, drug abuse, etc. Both the health authorities and the health insurance funds have retained a traditional orientation towards curative medical services, with a bias towards in-patient care in hospitals, while preventive activities have been given a much lower priority. The health authorities are
allocating most of their resources to medical treatment, and the health insurance funds are mainly paying for hospitalisation and visits to doctors. Very limited resources are spent on prevention and health promotion [8]. The health insurance is financing health examinations of children and some vaccination programmes, while the health authorities are financing programmes for prevention of communicable diseases. According to some of the interview persons, these programmes are not very useful. “Both the health authorities and the health insurance funds are run by physicians, and their approach to prevention is to start from diseases. Prevention is understood as screening for separate diseases.” Most of the activities related to disease prevention and health protection are controlled and financed directly by the federal Ministry of Health. In the ministry, there is a Sanitary and Epidemiological Department, which is responsible for prevention of communicable diseases and environmental problems like air and water pollution. To perform these functions, the department has a number of sanitary and epidemiological centres in each region controlling the quality of air, water, food, etc. In addition, each hospital must report all infectious diseases to the regional centres. This is the so-called San-Epid system, which is another heritage from the Soviet period. The system performed an important role in disease control during this period, but it has not been able to adapt to changing circumstances. In the words of one of the interview persons, “it is a control structure, based on a narrow laboratory approach to prevention and focusing on traditional hygiene.” There are also a number of research institutes belonging to the Russian Academy of Medical Science that are dealing with prevention and health promotion, for example, the Institute of Preventive Medicine and the Institute of Health Promotion. These institutes are not only conducting scientific research, but they are also actively involved in preventive activities. The Institute of Preventive Medicine is working with screening and vaccination programmes, for example, screening for tuberculosis and vaccination against polio, together with municipal departments for disease prevention. The Institute of Health Promotion is working with health information and education together with regional centres for medical prevention. These centres are not so active, however, and they have very limited resources. Some of the interview persons were also
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
critical of their work. “They are mostly run by retired physicians, old ladies who are not so interested in the development of the field, only in producing brochures.” Beside the activities of the health sector and the academy of medical science, there are preventive activities going on also in other sectors of the society, although they are not formally recognised as parts of the Russian organisation of public health. One of the most important sectors is the social insurance system. Based on a tradition from the Soviet period, the social insurance is financing prophylactic treatment and rehabilitation of workers and their families in sanatoriums, health resorts and children’s summer camps. These institutions are run by trade unions, local authorities or private entrepreneurs, but their activities are financed to a large degree by the social insurance. This is not only for historical reasons. As one of the interview persons explained, “the social insurance system regards these activities as investments in the health of the working population, which are supposed to pay off in the form of a reduced need for sickness benefits.” The Russian system of social insurance is administered by the social insurance fund and controlled by the Ministry of Labour. The social insurance fund is a centralised federal organisation with regional and industrial branch divisions. Like the health insurance, the social insurance is financed by insurance contributions from public and private enterprises and institutions, but it is covering only the working population. Most of the contributions are spent on sickness cash benefits, but the fund is also paying a number of other benefits and allowances. Around 25% of the total resources are spent on buying vouchers to sanatoriums, health resorts and children’s summer camps [11]. These vouchers are distributed for a reduced price to workers and their family members by social insurance committees in the enterprises. The distribution and the price of the vouchers are decided on the basis of medical prescriptions and the social situation of the workers. The sanatoriums and health resorts offer prophylactic treatments for a broad spectrum of diseases. The children’s summer camps have no medical facilities, but they offer prophylactic and recreational activities to improve the health status of the children. According to the interviews, these institutions and the activities they offer are beneficial, both for the people and for the national economy. There is also some statistical evidence to support this claim [10]. During the last years,
289
however, the financing of these activities by the social insurance system has been questioned. Some of the interview persons were regretting this development. “If the social insurance financing is reduced, the sanatoriums and health resorts have to become more and more commercial in order to survive. This means that the people who need them most will not be able to afford their services.” Beside the activities of the health sector, the academy of medical science and the social insurance system, there are also other sectors involved in the Russian organisation of public health. The educational sector has an important role in connection with health information and health education. There are, for example, campaigns in the schools for physical exercise and a healthy life style. There are also preventive activities in many enterprises, for example, medical examinations and prophylactic treatments for the employees and their families. Finally, there are a number of non-governmental organisations working with prevention and health promotion. These organisations are voluntary and have very little resources. They are mainly concentrating on certain population groups, such as handicapped children or elderly. There are also voluntary organisations working together with the church and the social authorities to prevent drug abuse. 3.2. Problems of co-ordination and collaboration The Government of the Russian Federation is responsible for the development of all the different sectors of the society. Within the federal government, one of the vice-premiers is responsible for all the developments within the so-called “improductive” sectors of the society, including health, education and social security. There is also an inter-ministerial committee, headed by this vice-premier, which is dealing with the co-ordination of activities between these sectors, including the activities of public health [11]. There have been a number of policy initiatives in this committee to co-ordinate the preventive activities of the health sector and the social insurance system. According to the interviews, however, these initiatives have not been very effective. As one of the interview persons put it, “the co-ordinating efforts on this level are creating a lot of paperwork, but very few concrete results.” There is not only a lack of co-ordination between the different sectors involved in public health, but also
290
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
very little co-ordination of the different activities within the health sector. As mentioned before, the preventive activities and the curative services are organised as two different systems. Most of the preventive activities are controlled directly by the Ministry of Health or the Academy of Medical Science, while the health services are controlled by the regional and municipal health authorities. Within the municipalities there have been some efforts to integrate the departments for disease prevention into the polyclinics, but the primary health care has shown little interest in preventive activities. Thus, in addition to the lack of co-ordination there is a limited collaboration between the different parts of the health sector. In a similar way, there is a limited intersectoral collaboration in addition to the lack of coordination between the health sector and other sectors involved in public health. On the federal level, the intersectoral collaboration is restricted to some international projects, for example, “Health Promoting Schools,” where the Ministry of Health is collaborating with the Ministry of Education. There is also some collaboration on the regional and municipal levels between the health sector and the educational sector. In St Petersburg, for example, the health authorities are working together with the school authorities in a project to prevent abortions and sexually transmitted diseases among teenagers. In Vologda, public resources have been collected from different sectors for prevention of non-communicable diseases. There are also non-governmental organisations and community groups involved in preventive activities together with the church and the social authorities in some regions and municipalities. According to the interviews, however, these examples are exceptional cases. “In general, health promotion and disease prevention on the regional and municipal levels is poorly financed, inadequately organised and badly co-ordinated.” There are few contacts and very little collaboration between the health sector and the social insurance system. Moreover, the relations between the two sectors seem to be quite problematic, particularly the relations between the health insurance funds and the social insurance fund. As one of the interview persons pointed out, “there is a competition for resources between the different funds, and both of them think that they are disadvantaged and could use the resources in a better way than the other.” There are also issues where the funds have conflicts of interests, for example, the rela-
tion between inpatient and outpatient care. The health insurance funds want to reduce the length of stay in hospitals in order to reduce the health care costs. The social insurance fund wants the patients to stay in the hospitals as long as possible in order to prevent aggravation of diseases and increased costs for sickness benefits. Another issue where there are conflicts of interests between the health insurance funds and the social insurance fund concerns the use of the sanatoriums and the health resorts. The social insurance is financing prophylactic treatments in these facilities in order to improve the health of the working population and reduce the needs for sickness benefits. The health insurance funds, on the other side, would like to use the sanatoriums instead for post-operative medical treatment and rehabilitation in order to reduce the need for hospitalisation. For this purpose, the health insurance funds would also like to take over the resources that the social insurance fund is spending on the prophylactic treatments. According to one of the interview persons from the federal health insurance fund, “the places in the sanatoriums should be used for people in real need of care instead of people who have only prophylactic needs.” There have been some efforts recently to improve the relations between the social insurance fund and the health insurance funds. They have had some collaboration in connection with rehabilitation after heart attacks and some major surgeries. The social insurance fund has provided vouchers for sanatorium treatment, which has been paid partly by the health insurance funds. There has also been a discussion about extending the compulsory health insurance to include also prophylactic treatments. The officials of the federal health insurance fund have been against such an extension of the insurance, however, since they think that it should not be used to finance prophylactic activities. According to one of the interview persons from the social insurance fund, “the federal health insurance fund does not recognise the value of the prophylactic treatments, but it benefits from the effects of these treatments on the health status of the population.” 4. Discussion The results of the interviews and the documentary studies show that there is a fragmented organisation of
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
public health in the Russian Federation. There are many different actors on the federal, regional and municipal levels of the health sector and in the parallel health systems for the military, the railway workers, etc. There are also important preventive activities going on outside the health sector, particularly within the social insurance system, where prophylactic treatment and rehabilitation is performed together with trade unions, local authorities and private entrepreneurs in sanatoriums, health resorts and children’s summer camps. There are also other sectors involved in public health, although their activities are on a much smaller scale. There are some preventive activities within the educational sector, particularly in the school system, and also in the enterprises, the social sector and the church. These activities are mainly on the regional and municipal levels of the society. There are also non-governmental organisations and community groups involved in public health activities on these levels. Together all of these actors, from different sectors and different levels of the society constitute the Russian organisation of public health. This is not an organisation in the usual sense of the word, but rather a “multi-organisation” consisting of many different interorganisational relations [17]. There is obviously a lack of co-ordination between the different actors in this organisation. The efforts of the federal government to co-ordinate the different sectors involved in public health are perceived not to be very effective. In a similar way, there is also a lack of co-ordination between the different actors within the health sector. The curative and the preventive parts of the health care system are working quite independent of each other and there have been no serious efforts to co-ordinate their activities. This lack of co-ordination in the Russian organisation of public health is not surprising, since it is very difficult to co-ordinate complex interorganisational systems in the traditional hierarchical way [18,19]. According to organisation theory, the absence of an effective hierarchical co-ordination may instead be compensated by a voluntary collaboration between the different actors. Collaboration means a more informal bottom-up approach in contrast to the traditional top-down approach of co-ordination [20]. There is, however, also a lack of collaboration between the different actors in the Russian organisation of public health. There is a limited collaboration be-
291
tween the curative and preventive parts of the health care system. There are some examples of intersectoral collaboration on the regional and the municipal levels of the society, but they are regarded as exceptional cases. In general, therefore, it seems to be very difficult to collaborate across the organisational boundaries of the Russian society, both within the health sector and between the different sectors involved in public health activities. The lack of intersectoral collaboration between the health sector and the social insurance system is particularly problematic. The health insurance funds and the social insurance fund show a territorial behaviour typical of a “tribal culture” [21]. This is probably another heritage from the Soviet period. In accordance with this culture, the different funds are defending their territories and trying to transfer costs to each other. There is also a competition for resources between the funds and a struggle to control certain institutions, like the sanatoriums and health resorts. In addition, there seems to be some “ideological” differences between representatives of the different funds, for example, in their view of prophylactic activities. The question is how intersectoral collaboration can be improved in the Russian organisation of public health, not only between the health sector and the social insurance system, but also between these sectors and the other sectors involved in public health. First of all, it would be important to improve the differentiation of roles and tasks between the different actors engaged in public health activities. They all have their separate responsibilities according to the legislation of the Russian Federation, but their joint responsibilities for public health are not regulated. A clear understanding of the roles and tasks of the different sectors may reduce many of the present problems of co-ordination and collaboration. This must be clarified by the federal government and by the actors themselves in a process of negotiation. Moreover, these roles and tasks cannot be defined once and for all, but have to be continuously discussed and reconsidered [22]. Secondly, it would be important to improve the integration between the different actors in the organisation of public health. One way would be to establish a national authority to initiate and support intersectoral collaboration in public health. However, with the size and traditions of the Russian society, there is a risk that such an authority would develop into a huge bureau-
292
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293
cracy, a “co-ocracy” [23]. Another way would be to encourage the different actors to form networks, partnerships, coalitions or alliances in different areas of public health. Experiences from other countries may serve as an inspiration in this connection [24,25]. Another way would be to establish special liaison committees on the regional and municipal levels of the Russian society. These committees could serve as forums or arenas for joint intersectoral decision-making on issues of public health. In these committees, it would be important to involve also non-government organisations and groups of empowered users, patients and other beneficiaries, who may be able to counteract the tribalism of the different actors and provide a more holistic view of public health [26]. The collaboration between the different actors in the organisation of public health is not an end in itself, however, but only a means to mobilise all the possible resources for public health activities and to use them in the best possible way. This is particularly important in the Russian Federation, considering the difficult economic situation and the bad health status of the population. Therefore, the intersectoral collaboration must be continuously reviewed and evaluated, both by the actors themselves and by the people who are subject to their activities. It would also be important to have systematic evaluations by independent agencies or research institutes in order to discover intersectoral problems and to promote organisational learning [27,28]. Such a process of continuous and systematic evaluation may lead to a development of intersectoral collaboration in the Russian organisation of public health.
5. Concluding remarks The analysis of the Russian organisation of public health has identified a lack of intersectoral co-ordination and collaboration, which is a serious problem considering the bad health status of the population and the need to mobilise all the possible health resources. Since an effective hierarchical co-ordination is difficult to achieve in a complex interorganisational system like this, the discussion has focused on different ways to improve the voluntary collaboration between the different actors involved in the organisation of public health.
Some of the improvements would however require radical cultural changes in the Russian society. As mentioned before, it would be necessary to change the culture of tribalism, which has been so strong in the state administration since the Soviet period. In addition to that, it would also be necessary to change the attitudes of the different institutions towards their users, patients and other beneficiaries. There is still a very authoritarian culture prevailing in most public institutions, and there is no tradition to listen to and consider the opinions of the beneficiaries. Finally, a continuous review and evaluation of intersectoral collaboration would require a culture of openness that does not exist among the actors involved in public health. Thus, with all the cultural changes required, it may take a long time to improve the intersectoral collaboration in the Russian organisation of public health. Since 2000, when most of the empirical data were collected, there have been some changes in the federal government, the tax system and the organisation of the ministries involved in public health. For example, the parts of the Ministry of Labour dealing with social development have been merged with the Ministry of Health. There have also been some recent reform proposals in the field of public health, linked to the WHO principles of health for all [29]. However, the implementation of these changes is slow and most of the intersectoral problems discussed in this article still remain. References [1] Acheson ED. Report of the committee of enquiry into the future development of the public health function. In: Public health in England. London: HMSO; 1988. [2] Frenk J. The new public health: reflections for the debate. In: The crisis of public health. Washington, DC: PanAmerican Health Organization; 1992. p. 68–85. [3] Ottawa Charter for Health Promotion. Health Promotion 1986;1:iii–v. [4] Weick KE. Sensemaking in organizations. London: Sage; 1995. [5] Hannan MF, Freeman J. Organizational ecology. Cambridge, MA: Harvard University Press; 1989. [6] Davies JK, Macdonald G, editors. Quality, evidence and effectiveness in health promotion. London: Routledge; 1998. [7] Saltman RB, Figueras J. European health care reform: analysis of current strategies. Copenhagen: WHO Regional Publications; 1997. [8] Tkatchenko E, McKee M, Tsouros AD. Public health in Russia: the view from the inside. Health Policy and Planning 2000;15:164–9.
R. Axelsson, S. Bihari-Axelsson / Health Policy 73 (2005) 285–293 [9] European Observatory on Health Care Systems. Health Care Systems in Transition: Russian Federation. Copenhagen: WHO Regional Office for Europe; 2003. [10] Bihari-Axelsson S, Axelsson R. The role and effects of sanatoriums and health resorts in the Russian Federation. Health Policy 2002;59:25–36. [11] Axelsson R. Institutional developments in the Russian system of social security: organizational and interorganizational aspects. Social Policy & Administration 2002;36:142– 55. [12] Field MG. The health and demographic crisis in post-Soviet Russia: a two-phase development. In: Field MG, Twigg JL, editors. Russia’s torn safety net. New York: St. Martin’s Press; 2000. [13] WHO. Health for all. Copenhagen: WHO Database; 2002. [14] OECD. The social crisis in the Russian Federation. Paris: OECD; 2001. [15] Taylor SJ, Bogdan R. An introduction to qualitative research methods. 3rd ed. New York: John Wiley & Sons; 1998. [16] Bowling A. Research methods in health. Buckingham: Open University Press; 1997. [17] Hjern B. Illegitimate democracy: a case for multiorganizational policy analysis. Policy Currents 1992;2:1–5. [18] Gray B. Conditions facilitating interorganizational collaboration. Human Relations 1985;38:911–36. [19] Alter C, Hage J. Organizations working together. London: Sage; 1993.
293
[20] Sanderson I. Effective inter-sectoral coaboration: the theoretical issues. Leeds: Health Education Unit, Leeds Metropolitan University; 1990. [21] Bate P. Changing the culture of a hospital: from hierarchy to networked community. Public Administration Review 2000;78:485–512. [22] Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. The Millbank Quarterly 1999;77:77–110. [23] Allen JE. Co-ocracy: a proposal for classifying coordinating organizations. The Bureaucrat 1975;4:163–80. [24] El Ansari W, Phillips CJ, Hammick M. Collaboration and partnerships: developing the evidence base. Health and Social Care in the Community 2001;9:215–27. [25] Mitchell SM, Shortell SM. The governance and management of effective community health partnerships: a typology for research policy and practice. The Millbank Quarterly 2000;78:241–89. [26] Barnes M, Walker A. Consumerism versus empowerment: a principled approach to the involvement of older service users. Policy and Politics 1996;24:375–93. [27] Axelsson R. Towards an evidence based health care management. International Journal of Health Planning and Management 1998;13:307–17. [28] Øvretveit J. Action evaluation of health programmes and changes. Oxford: Radcliffe Medical Press; 2002. [29] WHO. Health for all in the 21st century. Geneva: WHO; 1998.