Russia and Former USSR, Health Systems of Dina Balabanova, Erica Richardson, and Richard Coker, London School of Hygiene and Tropical Medicine, London, UK Ó 2017 Elsevier Inc. All rights reserved. This article is an updated version of the previous edition article by Dina Balabanova, Richard Coker, volume 5, pp. 627–637, Ó 2008, Elsevier Inc.
The Sociopolitical Context The fall of the Union of Soviet Socialist Republics (USSR) in 1991 led to a widespread drive for national autonomy, with the former republics achieving independence as countries shortly after. This coincided with radical political and economic liberalization, accompanied by an expansion of market forces and the building of new geopolitical relationships with the United States, the European Union (EU) and its member states, China, and Iran. Some of the changes that took place reflected a popular desire to move away from the legacy of the past, while in others, external forces played a major role. In some countries, rejection of communist ideology was combined with a strengthening of nationalistic sentiment, the former being identified with Russian dominance. However, change was more often unplanned, brought about by the economic collapse arising from the disruption of existing production and trading relationships. In some territories, this was exacerbated by armed conflict (Given their historical context and their membership of the European Union since 2004, the Baltic states of Estonia, Latvia, and Lithuania which also gained independence from the USSR in 1991 are not covered here.). The social consequences of the breakup of the USSR were significant. In many cases, the collapse of whole industries that were no longer competitive in the global economy led to widespread poverty, unemployment, macroeconomic instability, and a decline in the population’s economic and social resources. In many countries, the gross national product declined by 50%. Almost everywhere, falling government revenues, spiraling inflation (and devaluation) meant financing for existing public health systems dried up. Nominally, they continued to operate, by paying wages late and avoiding any investment in equipment and facilities. This led to an insidious deterioration in health-care structures and their ineffective functioning. In places, the collapse was particularly rapid, notably in social security protection and other public services. Migration, erosion of social networks and values, armed conflict, and the rise in high-risk behaviors such as selling sex, alcohol abuse, and drug use contributed to social disruption and compounded economic insecurity. International development assistance for health in the region was low relative to the health and economic needs these countries faced (Suhrcke et al., 2005). The countries of the former USSR vary widely in terms of historical and cultural background, population homogeneity, income levels, and political processes. Armenia, Azerbaijan, Georgia, Kyrgyzstan, Moldova, Tajikistan, and Ukraine have experienced significant economic crises, geopolitical pressures, conflict, and political unrest, with large numbers of their populations being displaced. While countries such as Turkmenistan and Uzbekistan have not established democratic institutions and processes or instituted fundamental economic reforms,
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others, such as Kazakhstan and Azerbaijan, have opened their markets but not their political processes. Belarus, Uzbekistan, and Turkmenistan have been relatively isolated geopolitically. The economic development of some countries in the region such as Russia, Azerbaijan, and Kazakhstan have benefited from access to natural resources, which expanded the resources available to the state when oil and gas prices boomed. However, these economies are also subject to the volatilities that come with having economies dominated by commodities, and falling oil prices have seen the population in these countries reexposed to financial hardship. Across the region, socioeconomic inequalities widened dramatically through the 1990s and access to public resources have not kept pace with more recent economic growth. As income differentials grew rapidly through the 1990s, a small hyperaffluent elite benefited substantially, while large sections of the population have suffered and become marginalized, particularly in rural areas. The size of vulnerable populations in the resource-rich countries shrank while oil and gas prices were high. However, the vulnerable population has grown again since the global financial crisis began in 2008, with migrants, ethnic minorities, the homeless, and people working in the informal economy being particularly at risk (Thomson et al., 2015). Attempts to mount effective policy responses to socioeconomic hardship were initially hampered by the weakness of functioning governance systems. The newly independent states had only limited experience in law making, good governance, and effective stewardship, and great effort had to be devoted to the drafting of constitutions and development of democratic institutions in the early years. Some of the countries also undertook administrative decentralization which posed new challenges to public services.
Health and Demographic Status The human cost of political, economic, and social transformation was enormous, particularly in the early years. The region experienced dramatic changes in its demographic and health indicators, which compare unfavorably with the indicators in Western Europe and countries in central Europe. After World War II, the Soviet system made considerable progress in establishing universal health and education systems, implementing universal immunization programs and eradicating cholera, malaria, and typhoid based on scaling up basic interventions. As a result, until the late 1960s, Soviet republics achieved increasingly good health outcomes given their level of economic development. However, the health-care and health promotion systems were less effective in implementing the more complex programs required to respond to the changing disease patterns and risk factors associated with aging, urbanization, and industrialization (smoking, heavy alcohol use),
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and noncommunicable diseases. As a result, since the 1960s, life expectancy in most countries of the former USSR did not improve in line with the advances in Western Europe. This epidemiological departure was driven largely by rising death rates from heart disease, injuries, and violence (Mackenbach, 2013). By 2000, life expectancy at birth was almost 15 years lower in the countries of the former USSR than in Western Europe for men, and 9.1 years lower for women (Figures 1 and 2). Russia, Belarus, and Ukraine in particular faced a major mortality crisis in middle-aged men, and across the region high mortality was driven by deaths from cardiovascular disease (Rechel et al., 2014). Since then, life expectancy in the former USSR has improved slightly, but the gap with Western Europe persists, especially for men (13.4 years for men and 8.8 years for women, 2011). The proximal reasons for this crisis can be attributed to lifestyle factors, particularly hazardous alcohol use, smoking, and poor diet, but also weaknesses in health care, particularly the poor control of hypertension (Roberts et al., 2012). It has been argued that these risk factors have been associated with poor psychosocial health and collapse of social security and long-term safety nets. While many of the reasons for this deterioration lay outside the health-care sector, the need for effective health care that can respond to these challenges and promote health has never been greater. In parallel to excessive mortality and morbidity from chronic diseases, some communicable diseases emerged as important public health threats, such as HIV/AIDS and tuberculosis (including multidrug-resistant strains) (Figures 3 and 4).
The health-care system in the Soviet Union is also known as a Semashko model, after its chief architect Nikolai Semashko (1874–1949). Semashko was a member of the Bolshevik Party and became the first Soviet People’s Commissar of Public Health in 1923 and initiated reforms that later became associated with the Soviet model of health care. The Soviet system sought to provide universal access through an extensive network of facilities and this was among the most visible achievements of the USSR. Evidence on system functioning and health outcomes predating the end of the USSR is limited, but there are indications that, at least formally, the health systems shared considerable uniformity in their design. However, this masked considerable inequalities between rural and urban regions and there were considerable shortcomings in basic infrastructure (such as persisting disparities in access to running water, Roberts et al., 2012) in Central Asia and the South Caucasus that were much less common in, for example, the Russian Republic. The basic elements of a health-care system in the USSR began to be put in place in the 1920s reflecting the communist regime’s imperative to build healthy workforce. These reforms accelerated during the late 1940s and 1950s through the establishment of a network of facilities that reached out into the most remote settlements, providing basic coverage to almost the entire population. The Soviet-style health-care model was replicated throughout Central and Eastern Europe after World War II. The health-care systems were publicly financed, through general taxation, with the state owning the facilities and providing all health services (Table 1). Access to care
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Figure 1 Life expectancy at birth, in years, male. From World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2015).
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Figure 2 Life expectancy at birth, in years, female. From World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2015).
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Figure 3 Estimated incidence of tuberculosis per 100 000 population (selected countries). World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2015).
was free at the point of use. The formal private sector was extremely limited. The system was labor intensive, and the health workforce was very large, mainly because it was possible to keep the wages of health professionals in the health sector low.
The health-care system focused on industrial workers, mothers, and children – reflecting the importance given to boosting population growth and the control of infectious diseases. Infant and maternal mortality fell rapidly, in part due to the expanded health-care system but also because of
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Figure 4 Incidence of HIV per 100 000 population (selected countries). World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2015) and World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed July 2013).
achievements in other sectors, such as nearly full employment and improved living conditions, albeit achievements made at a huge human cost. The infrastructure and quality of care were, however, uneven, with urban areas benefiting from increased investment in line with the emphasis on industrial production.
Table 1
Semashko model: key characteristics
Advantages l Universal entitlement to a comprehensive package l Publicly financed and delivered health care. No access barriers for the majority of the population l Full geographical coverage l Extensive and integrated network of facilities l Emphasis on population-oriented prevention, public health initiatives l Centralized planning, management, and policy making Disadvantages l Hidden inequalities (informal payments, preferential treatment of certain groups) l Poor quality and responsiveness toward individual needs l Deprioritization and underfunding of the health sector. Deteriorating infrastructure and underfunded running costs l Extensive labor and capital inputs but low efficiency l Hospital-dominated systems, emphasis on curative and specialist care. Low status of primary care and public health services l Limited attention to evidence-based medicine l Political interference into the health sector funding and delivery Based on Preker, A.S., Feachem, R.G.A., 1995. Market Mechanisms and the Health Sector in Central and Eastern Europe. World Bank Technical Paper Number 293. The World Bank, Washington, DC.
Following reforms in the 1970s, the Soviet health system was both integrated and vertically structured, with precisely defined responsibilities for each level of care. Services were provided through extensive networks of facilities covering designated catchment areas. The primary care level consisted of polyclinics (and subordinate rural ambulatories) typically staffed by district physicians and several specialists with basic training. Rural ambulatories and health posts often employed feldshers or community-based health workers who often served state-owned collective farms. Primary care facilities were subordinated to district-level, regional hospitals for secondary care, and referral institutes for tertiary care. While polyclinic care was relatively accessible, close to the community and free at the point of use, it was often perceived to be of low quality and bypassed. The health-care system had a strong hospital based and specialist care orientation, since primary care providers had only basic skills and equipment, and provided limited services; they did not function as gatekeepers so much as dispatchers to higher levels of care. As a result of these regulatory and financing arrangements, the health system grew to be increasingly overspecialized. There were also separate specialist structures, for example dispensaries, which ran vertical disease control programs dedicated to sexually transmitted diseases, mental health, tuberculosis, cancer, etc. These were in addition to sanitaryepidemiological stations responsible for public health initiatives such as monitoring water quality, regulating food hygiene, and infectious diseases surveillance. These had separate management structures and information systems. There were also parallel services for people working in the defense
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industries and the military, the transport sector, and other large state employers. This parallel provision highlights the priority afforded to industrial workers in the wider Soviet economic system. The system was centrally planned meaning the central authorities were responsible for management, resource allocation, and regulation. The health system was regulated by the All-Union Ministry of Health and its branches, through a centralized system of decrees which regulated the structure of the health system, providing norms for staffing, facilities, and operational procedures such as frequency of visits and procedures (e.g., antenatal visits, health checks). The central Ministry of Health decrees also set treatment standards, although these were often vague and provided general guidance rather than specific directions for clinical care. Treatment standards were most often based on advice from leading specialists and traditions rather than upon the emerging internationally accepted paradigm of evidence-based medicine. Health sector financing was determined on a residual basis – after the needs of other sectors had been met – and was below that of other industrialized countries. Furthermore, resource allocation was inefficient, based on fixed norms for the number of staff and beds per population, on a historical basis, and not taking into account the volume of services provided or the quality of clinical activity or health outcomes. Access to the health system was universal and free at the point of use in the USSR, and out-of-pocket payments were low; nevertheless, access to good-quality care was increasingly inequitable. Members of the Communist Party elite, as well as sectors with parallel health systems, such as the military and employees of some state industries, had privileged access to care and pharmaceuticals that were considered to be of much higher quality than the average. Access to these parallel providers could only be obtained through patronage. Anecdotal evidence suggests that access to good-quality care was increasingly dependent on providing gifts or services. The system could not supply medical equipment and pharmaceuticals that were becoming routinely available in other industrialized countries, in part because of lack of funds but also because of restrictions on imports from Western countries that were concerned about the use of advanced technology for military purposes. By the late 1980s, the system was struggling to respond to the needs of the population and was becoming increasingly ineffective, inefficient, and obsolete (European Observatory on Health Systems and Policies, 2006). After 1991, in many places, the system collapsed in the face of serious financial shortages following the collapse of the USSR. This triggered a huge increase in out-of-pocket payments, and reduced coverage of essential interventions.
Health-Care Systems and Reform Since Independence Current Status Variations across the health-care systems of countries in the region reflect diverse political and economic trajectories. The political and economic transition as well as declining government financing and support for market-based reform led to a dramatic depletion of resources available for health-care
systems across the region. While public health-care spending in Russia remained relatively stable at around 3–4%, in Azerbaijan, Georgia, and Armenia it has been in the range of 1– 2% of GDP throughout. Across the region, out-of-pocket expenditure on health ranges from 71% of total health expenditure in Azerbaijan (2013) to 32% in Belarus (WHO HFA database 2015). With the collapse in public funding, reliance on out-of-pocket payments by users to access care and pharmaceuticals has grown. Formal and informal out-of-pocket payments to obtain what is perceived to be good-quality health care became increasingly common across the region (Balabanova et al., 2004), although to different degrees (Lewis, 2002; Falkingham, 2004). For the poor, out-of-pocket expenditures often represent a barrier to care, thus restricting demand (Balabanova et al., 2012). The situation has become particularly acute for outpatient pharmaceuticals which dominate out-of-pocket spending across the region. Pharmaceutical costs can impoverish households where members have a chronic condition and many patients forego pharmaceuticals (Footman et al., 2014; Murphy et al., 2013). Unlike the situation in many other parts of the world, where reduced access to the health-care system has arisen following often donor-driven policies to implement user charges, in the former USSR it is a consequence of dramatically reduced resources, in systems formerly reliant on extensive growth. Wider policies of economic liberalization, the introduction of market mechanisms replacing traditional state functions, deregulation, and decentralization have also influenced the architecture of reforms. Despite official commitment to guarantee universal coverage, with guarantees covering virtually all medical conditions apart from cosmetic surgery and dentistry, the reality is that profound barriers to access exist for substantial populations. Despite changes in the way health systems are financed in some countries (with many countries moving from taxation to social insurance models), most health-care facilities continue to receive budgets allocated according to number of beds and staff, rather than volume or quality of services (Rechel et al., 2014). Moreover, public health systems remain heavily dependent on parallel vertical programs. Medical associations are still not in a position to act as self-regulatory bodies. In addition, because of an underdeveloped civil society and low awareness of public sector entitlements, patients have limited opportunities to question clinical decisions and cost of care. There has been some, though variable penetration of the principles of evidence-based health care that were previously rejected by the traditional Russian scientific orthodoxy. Physician-to-population ratios continue to be high, but there is wide variation across the region in the supply of nurses. The skill mix, especially in urban settings, remains in favor of training and retaining physicians, rather than midwives, nurses, and auxiliary staff, or developing new, innovative approaches through training and employment of nurse practitioners. In contrast, in rural areas, difficulties in recruiting, continually training, and retaining health-care workers means that, in practice, unsupported staff with narrow skills have often had to take on significant responsibilities (Danishevski et al., 2006b). Despite high staff capacity, health services continue to be unresponsive to user needs, and user satisfaction remains low in most countries (Footman et al., 2013).
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Health System Reform Over the past 25 years, most countries in the region have sought to implement wide-ranging reform programs of both health-care financing and delivery of care models. Some countries have implemented comprehensive and acclaimed reform programs with monitoring and evaluation components (e.g., Kyrgyzstan), while others have adopted a piecemeal approach (e.g., Ukraine) (Boxes 1 and 2). Despite differences between countries, given the similarities in the health systems they inherited at independence, most countries have faced similar
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challenges. Several major groups of reforms have taken place in the region. 1. The main radical health financing reform was a move from a tax based to a mandatory health insurance system, seeking to cover the whole population with a comprehensive package of services. At different times this has happened in Russia, Moldova, Kyrgyzstan, Kazakhstan, and Georgia (Rechel et al., 2014). The mandatory health insurance model has formally upheld the principle of universal access to care, while seeking to mobilize earmarked resources to safeguard
Box 1 Kyrgyzstan as a regional health system leader and innovator* Kyrgyzstan is considered as one of the most successful reformers in the former Soviet Union region (Kutzin et al., 2010b; Balabanova et al., 2013) due to the coherence and continuity of reform associated with major advances in health and access to services (Balabanova et al., 2011). Despite considerable political instability, two revolutions, and armed conflict, Kyrgyzstan designed and implemented a series of extensive policies. Being one of the poorest republics of the USSR, mountainous and with limited natural resources, the country faced almost total collapse of government expenditure and the health system after gaining independence in 1991. The radical reform began soon after, driven by the severe public sector contraction but also as political leaders and elites seized the opportunity to attract foreign aid. The government endorsed the ambitious Manas (1996–2006), and Manas Taalimi (2006–2010) programs, as a blueprint for comprehensive health system transformation. The clear and coherent vision and plans attracted considerable technical and financial support from the international community and led to the only sector-wide approach (SWAP) in Central Asia (Rechel et al., 2011). Reforms were implemented despite a sharp drop in total health expenditure as a percentage of GDP in the late 1990s. The success of the reform was explicitly linked to government effectiveness, promoting accountability. The cornerstone of reform was to restore universal coverage through a mandatory health insurance system, which expanded gradually over time to cover over 80% of the population. The State Guarantee Benefit Package covers the whole population, and an Additional Drugs Package subsidizes essential medicines; both are revised annually to reflect available funds. A ‘single payer’ system for providers now links resource allocation to performance using a prospective case-based system for inpatient care and a capitation-based payment for primary care. Kyrgyzstan has also succeeded in strengthening primary health care and shifting care out of hospitals. Modern family practices and upgraded community health centers have expanded access among rural populations. Most primary care physicians trained under the Soviet system had limited clinical skills and were retrained as family practitioners. Village health committees staffed by volunteers supported public health and health education initiatives. Kyrgyzstan was the only country in the former Soviet Union that radically downsized its inherited inefficient and poorly resourced hospitals (42% closed in 2000–2003), redirecting funding to patient care (Kutzin, 2003). A policy of creating and retaining a cadre of managers and planners, and reducing political influence over appointments and promote institutional stability has promoted transparency in the system. Reforms developed through pilot schemes, making it possible to learn lessons and scale up effective interventions. These were evaluated and informed national policy cycles but also practice creating feedback loops. Research institutes were embedded into the policy process to support knowledge uptake. Successful early initiatives to tackle resource allocation, regional disparities and informal payments have been unique in the region (Jakab and Kutzin, 2009). While the improvement has been remarkable in regional context, maintaining coverage, addressing complex chronic diseases and responding growing population expectations requires continued and sophisticated reforms. *
Adapted from Balabanova, D., Mills, A., Conteh, L., Akkazieva, B., Banteyerga, H., Dash, U., et al., June 15, 2003. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 381 (9883), 2118–2133.
Box 2 The impact of not reforming the Semashko system in Ukraine* In Ukraine, successive governments have struggled to overcome funding shortfalls and modernize the health care system to meet the population’s health needs. There has been considerable decentralization in the system since independence; however, in most other respects, the system remains largely unreformed. Many of the core features of a Semashko system have been retained, with an extensive infrastructure and a strong bias in the system towards inpatient care. Consequently, most resources are spent on running costs for the health infrastructure rather than patient care while primary care has remained weak (Lekhan et al., 2015). Allocations and payments are still made according to strict line-item budgeting procedures. This means payments are related to the capacity and staffing levels of individual facilities rather than to the volume or quality of services provided. The number of acute care hospital beds in Ukraine is high by international standards but despite this, operating indicators show that utilization remains quite high and, once admitted, patients on average stay for 10 days. Research has shown that almost a third (32.9%) of hospitalizations in Ukraine are unnecessary (Lekhan et al., 2015). Consequently, operating indicators remain high despite the development of day care and other schemes that could potentially substitute inpatient care. Chronic underfunding has allowed the gap between the Constitutional promise of universal coverage and the reality of what is provided for free at the point of use to widen. Formal salaries for health workers are extremely low and this, with the absence of sustainable health financing, has resulted in a plethora of formal, quasiformal and informal payments in the system. A large proportion of total health expenditure is paid out of pocket (42.8% in 2013) and households face inadequate protection from impoverishing and catastrophic health care costs, particularly if they have chronic conditions as most out of pocket payments are to cover outpatient pharmaceutical costs.
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Patients in Ukraine do not have great trust in reform programs and often resist changes such as the introduction of gate keeping in primary care. Patients have a strong preference for consulting hospital doctors and believe that hospitals provide the best quality care. These hospitals are also accustomed to the flow of formal and informal funds and there are many in the health system who are happy with the status quo. These vested interests are often very powerful in their own right and effective at mobilizing support from their patients to protest changes. The key challenge in reforming the health system has been the lack of political will to change things when politicians do not want to be unpopular or attract powerful enemies. These challenges are not unique to Ukraine, but it will take a level of political bravery as yet unseen to implement fundamental reform of the health system. Improving efficiency, quality and access to health services that are people-centred is therefore a great challenge, but even more so at a time of financial, political and humanitarian crisis. * Adapted from Lekhan, V. Nitzan-Kaluski, D., Jakubowski, E., Richardson, E., 2015. Reforming the Ukrainian health system at a time of crisis. Eurohealth 21 (2), 14–17; Lekhan, V., Rudiy, V., Shevchenko, M., Nitzan-Kaluski, D., Richardson, E., 2015. Ukraine: health system review. Health Sys. Trans. 17 (2), 1–153.
health-care funding flows, and promote strategic purchasing. However, other explicit objectives were to improve transparency and accountability of health sector financing and its dependence on short-term political priorities. The shift from central government budgets to mandatory health insurance has involved varying degrees of competition and state subsidy. In most countries, there is a nominal separation of purchasing and provision, with independent insurance funds acting as third-party payers. However, the shift to a mandatory health insurance model requires complex systems, and this has been hampered by poor administrative capacity and information systems, and high transaction costs. It also failed to significantly increase resources for health care, as shown by the example of Kyrgyzstan and Georgia (Bonilla-Chacin et al., 2005). Sustaining funding levels has relied on budget subsidies because relying on employment-based health insurance has been incompatible with patterns of informal employment, rural poverty, and noncash economies. Even with these budgetary transfers, certain vulnerable or marginalized groups have been consistently excluded (Richardson et al., 2012). In Armenia, Georgia, and Azerbaijan there have also been experiments with microinsurance schemes for rural, isolated populations that tend to lack coverage – which rely on community management and solidarity. While these schemes have provided a vital first-line service, the scope and quality of care is basic (e.g., excluding care for common chronic conditions), participation remained low, and scaling up proved too challenging (Poletti et al., 2007). The schemes also suffer from generic problems with microinsurance, such as small risk pools, lack of cohesive communities, poor administrative capacity, and inability to attract subsidies. 2. Changes to delivery of primary care across the region have sought to strengthen primary care and reorient the system away from its reliance on inpatient care through the development of general practice (family medicine) to replace the former polyclinic-based model. Reforms have also included introducing new types of clinical training and primary care financing mechanisms such as capitation-based payments. However, despite efforts to shift the health system orientation toward primary care with a strong gate-keeping function, in reality progress has been slow (Rechel et al., 2014). In Russia, where efforts to recruit and train family doctors has been considerable, newly trained professionals have often returned to practice in polyclinics where they are not provided with resources or incentives to practice as family doctors and often revert
to old models of practice, or they face unemployment (Rese et al., 2005). Professional demarcations also persist. For example, in Kyrgyzstan and Georgia, despite primary care physicians receiving training in managing diabetes and other complex chronic diseases, in practice all care continues to be provided by specialists (Hopkinson et al., 2004). 3. Management training for administrators remains limited and systems of resource allocation and reporting inherited from the Semashko model are still in place in some countries, with important implications for the sustainability of reform models and the introduction of incentives to engineer change. Increasing managerial autonomy has been the express goal of reform programs in, for example, Moldova, Kyrgyzstan, and Kazakhstan, but politicians continue to influence many key decisions. 4. Efforts to create a private sector or liberalize existing provision have largely been limited to the pharmaceutical sector, dental care and outpatient diagnostic services in urban settings, where the ability to pay is greater. The private sector remains limited across the region with voluntary health insurance covering limited scope of services and proving unaffordable for most. 5. In the 1990s, many countries sought to decentralize their health-care systems, allowing regional and municipal administrations to fund and deliver health care while still formally observing the norms established by the Ministry of Health (Rechel et al., 2014). The move to decentralization and regional autonomy, with the intention of creating more locally responsive, although less coordinated, systems led to declining stewardship of national institutions, such as the Ministries of Health and public health authorities. Duplication of functions at different levels of the system and the mixed accountability lines reduced the efficiency of the heavily decentralized systems overall. Consequently, over the past 10 years, there has been greater emphasis on recentralizing and defragmenting the health systems to rationalize financial flows and improve quality of care in, for example, Russia, Ukraine, and Kazakhstan. Nevertheless, decentralization and recentralization efforts have served to weaken linkages between the multiple horizontal and vertical (disease-specific) services, with the effect particularly visible in the area of infectious disease control (HIV and TB), where concerted action between the specialized facilities and the general system has been particularly difficult to achieve. The vertical nature of donor-driven initiatives in these fields has also reinforced these specialized disease-specific silos.
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6. Professional organizations of physicians have been reestablished, but play a relatively limited role in training, licensing, and quality control in most countries. They have also become partners in health sector reform through helping to set clinical guidelines and advising on packages of care under mandatory health insurance. Associations of nurses and other professions allied to medicine have been less influential. Patient organizations have also emerged, but they play a marginal role in national policy making and mostly provide health information, education, and smallscale service delivery to particular constituencies. Despite ambitious reform programs in most of the postUSSR, the health systems in many countries retain much of their previous orientation, structures, and ethos (see for example Box 1 on Ukraine). Where reforms have been successfully implemented, they have had some success in addressing inefficiencies in the inherited system and improving access to primary health care (see for example, Box 2 on Kyrgyzstan). Implementation has proved challenging in many instances because radical reform initiatives have been placed in the context of old resource allocation patterns, institutions, and attitudes which undermines their potential for bringing about change.
Access to Health Care: The User’s Perspective Following the dissolution of the USSR, people in this region experienced much greater barriers to accessing effective health care. A study in eight of the former Soviet countries demonstrated the extent to which the principles of universal access that underlined the former Soviet health systems were eroded (Balabanova et al., 2004). A follow-on study in the same eight countries found that within-country inequalities and access to care had improved, with the notable exception of Ukraine, but almost half of respondents who had a health problem in the previous month had still foregone health care (Balabanova et al., 2012). Respondents in Armenia, Georgia, and Ukraine were significantly less likely to seek care and cost was most often cited as the reason. Moreover, there is evidence that across the region traditional (i.e., nonbiomedical) remedies are chosen as a more affordable, and sometimes more trusted option (Stickley et al., 2013). Self-medication, both with traditional remedies and with biomedical drugs purchased without prescription, is often a strategy to bypass the mainstream health services, which tend to be associated with high access costs. Informal payments and in-kind gifts were frequent during the Soviet era as a form of ‘gratuity’ payment given to the doctor after a consultation or an operation. Reasons for this practice were numerous but gifts and informal payments were commonly seen by the population as a way to compensate generally underpaid medical staff. Informal out-of-pocket payment is still frequent across the former USSR, but the nature of informal payments has changed and many are now levied according to fixed ‘rates’ and requested in advance of treatment. Rates are set either by facilities or individual staff and take into account the patients’ perceived ability to pay (Kutzin et al., 2010a). Informal payments are not equally distributed among health services and health personnel; for example, they are more prevalent in inpatient than outpatient facilities. Informal payments are also more widespread in health services that are
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perceived by patients as being immediate and unavoidable, such as surgery and obstetrics; they can also vary by level of specialization or the complexity of the case (Rechel et al., 2014). During the Soviet period, it was impossible to study socioeconomic inequalities in health status and expenditure. Although such research is now possible, it remains rare. In contrast to the media attention devoted to political and economic changes in this region, the impact of these changes on the health of individuals and families remains poorly recognized. In a single year, 1 in every 160 households in Kyrgyzstan and 1 in 25 in Ukraine faced catastrophic expenditure due to health costs (Xu et al., 2003). In Tajikistan and Turkmenistan, substantial inequalities have been documented in access to care as services become unaffordable for the poor (Falkingham, 2004; Rechel and McKee, 2005). The case of abortion also demonstrates how gaps in access to care can occur even where overall utilization is high (Parkhurst et al., 2005). Abortions have been widely used as a method for birth control in the former USSR and rates in many countries remain high. Although abortion is legal and readily accessible in all the countries, abortion complications are a leading cause of maternal death in Georgia, Armenia, Azerbaijan, and the Russian Federation. In Belarus, where maternal mortality rates have fallen to below the EU average, abortion complications are no longer a leading cause of maternal mortality and rates have fallen to below the EU average. Certain groups such as migrants and those without a permanent address are particularly at risk and may face barriers in accessing care due to bureaucratic obstacles and informal pressure to pay. Mothers under 18 remain under the care of pediatric services, which have poor links to sexually transmitted infections (STIs), maternal, and reproductive services. Awareness of modern contraception methods is high, but in practice they are often inaccessible or unaffordable, resulting in high rates of unplanned pregnancy.
Emerging Challenges Responding to Chronic Disease The health systems in the region continue to face considerable challenges. The rising burden of chronic noncommunicable disease requiring reliable life-sustaining treatment requires complex and innovative system responses. It is increasingly demonstrated that adequate financing of services and appropriate infrastructure is only the starting precondition to achieve good service. Integrated care involving coordination and effective communication between multidisciplinary teams, at different levels of the health system is essential for effective chronic disease management. Good governance and accountability is crucial to achieve universal and responsive patientcentered care. Active involvement of patients and their representatives is also a key to successful chronic disease management. However, these needs are at odds with the Soviet-style top-down management and paternalistic culture in the former USSR, a pattern that persists in many countries. Although there are well-established models for chronic disease management internationally, their application in former USSR countries appears increasingly problematic. Patterns of clinical practice that are based on the labor-
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intensive model remain in place, and there is a lack of investment in appropriate skills, equipment, facilities, and knowledge to implement more effective chronic-care models. Management of chronic conditions such as diabetes, hypertension, epilepsy, or asthma is particularly poor at the primary care level and most chronic care is still conducted by highly specialized staff with no means of achieving continuity of care. Some diseases can illustrate health system failures. For example, premature death rates from diabetes increased markedly in many former USSR countries in the 1990s. In Ukraine, verbal autopsy interviews with relatives of those who had died prematurely show that despite the maintenance of access to care, people with diabetes suffered from numerous problems, with shortages of drugs and equipment and poor-quality care (Telishevska et al., 2001). A similar picture has been described in Kyrgyzstan (Hopkinson et al., 2004). Chronic-care systems are fragmented, and linkages between levels of care and different specialists are lacking. As a result, clinical outcomes have worsened, with admissions of patients with complications or in coma, especially among those living in rural areas, on the rise. The reasons for this deterioration in clinical outcomes are complex. The Soviet health-care system was never geared toward managing such conditions at the primary care level, especially in rural areas. Although change was being implemented, with a well-designed program in the major cities, too often the necessary institutional and sectoral connections had not been made. For example, investment in training for the management of diabetic complications is not embedded in the system through formal channels and the availability of necessary equipment where required. For example, family physicians despite their training still often do not play a major role in the treatment of noncommunicable disease and are expected to refer patients to hospital specialists. As noted, professional resistance plays a part along with unsupportive institutional environments. Linkages between social services and health systems are weak, complicating the pathways to the treatment and obtaining the benefits to which users are entitled. In addition, there were major problems with access to pharmaceuticals after the dissolution of the former USSR. Despite access to insulin often being funded by international donors in a range of countries, in some places, there were major bottlenecks in procurement and distribution of supplies (Hopkinson et al., 2004). Pharmaceuticals are now widely available in most places, but access is severely hampered by their cost as most outpatient pharmaceuticals need to be purchased out of pocket (Rechel et al., 2014).
Responding to Communicable Disease In the 1990s, most countries in the region experienced rising rates of tuberculosis and HIV, and in some countries reemergence of malaria, diphtheria, and cholera (World Health Organization Regional Office for Europe, 2006). At the end of 2013, there were an estimated 1.1 million people living with HIV in the former USSR, with over 85% of them living in Russia or Ukraine (UNAIDS, 2015). The epidemic is concentrated among people who have injected drugs, and in Ukraine, consistent harm reduction policies have succeeded in reducing the number of new HIV cases, while in Russia, where policies
have been hostile to harm reduction, the rate of new infections has continued to grow. It has been estimated that 1.8 million Russians inject drugs (2.3% of the adult population) – more than double the estimates for other countries in the former USSR. Responding to HIV posed a great challenge to public health systems. Initial responses focused on widespread population testing, but this was not linked to any strategic goal. Most individuals diagnosed with HIV were left without hope. For a few individuals, intermittently available monotherapy with antiretrovirals was offered. Since HIV treatment for all has become part of global political rhetoric (if not reality), determinations of who should receive treatment, the consequences of drugresistant HIV, and the challenge of managing, resourcing, and coordinating prevention activities as well as treatment programs is proving a formidable challenge. Across the region, the coverage with antiretroviral therapy is still poor, which is reflected in the high AIDS death rate in Russia, which accounted for 4% of all AIDS deaths globally in 2014 (UNAIDS, 2015). Generally, control of communicable diseases is hampered by inadequate surveillance and diagnostic systems, limited capacity (infrastructure and skills) in delivering effective public health interventions, despite the existence of sanitaryepidemiological stations and vertical subsystems within the broader health system. This challenge is not helped by the vertical, disease-specific nature of the TB- and HIV-control health system structures. In most countries, testing and treatment for HIV, TB, and STIs is performed in a range of institutions (regional AIDS centers, narcology departments, dermatology and venereology, prison service, sanitaryepidemiological stations) as well as in the private sector, with differing funding and delivery arrangements. While considerable variations exist across the region in terms of control efforts and epidemiological trajectories, the lack of integration between, for example, testing and treating, penitentiary and civilian, and HIV care and TB control systems, means that integrated, patient-centered care is absent. This fragmentation of care, and the difficulty of tracing and retaining people in the health system, and to implement system-wide interventions involving different sectors such as social services, prison health services, police, and education has its roots in the Soviet public health-care model where few incentives were built in to ensure improvements in clinical outcomes. In the case of tuberculosis, surveillance systems are struggling in the face of underfunding, reliance on obsolete systems and infrastructure, and a lack of epidemiological capacity. Cure rates fell from the mid-1980s, and erratic treatment adherence coupled with uncertain antituberculosis drug supplies have contributed to the emergence of multidrug-resistant TB. Inadequate linkages between parallel health systems, for example between civilian and prison institutions, allowed many patients to fall between the gaps (Coker et al., 2003). Administrative inertia, combined with high-level skepticism regarding the evidence base for DOTS (the World Health Organization’s TB control strategy), cultural resistance to clinical standardization, and a reluctance to forego radiologically based approaches to diagnosis, meant that internationally accepted approaches to control were slow to be embraced. In recent years, Russia, Ukraine, and Belarus, have started to pilot DOTS approaches, but with a heavy dependency upon external
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aid. DOTS has not been embedded systemically, with implementation largely supporting vertical approaches to disease control that are not integrated into wider health systems; managerial and financing systems hinder effective change (for example, because payment systems create perverse incentives and do not reward performance). WHO-advocated models may be unsustainable if donor support dries up (Atun et al., 2005; Marx et al., 2007). The lack of intersectoral collaboration is particularly vital in the failure to support identification and treatment of marginalized groups, such as prisoners, people without passport registration, and the homeless (Coker et al., 2003). In the former USSR, HIV infection is concentrated among vulnerable and marginalized groups such as injecting drug users (IDUs), commercial sex workers, and prisoners, who often lack access to basic services. These groups are often stigmatized and discriminated against by health staff, and their needs are not adequately addressed, causing poor adherence to treatment and lack of trust in the public systems. This is a major problem in assessing the scale of infection, detection of new cases, and treatment. There is limited collaboration with the civil society in targeting such groups (Atun et al., 2005), although in some countries such as Kyrgyzstan and Ukraine, NGOs act as service providers for marginalized populations (e.g., IDUs). As for the treatment of chronic disease, communicable disease management, such as for tuberculosis, relies on frequent and prolonged hospitalizations, mostly aimed at increasing treatment adherence and retaining patients within the system, sustaining institutional funding (allocated according to existing infrastructure and bed occupancy), or to provide social (rather than medical) care for highly marginalized populations.
Conclusion The public health consequences of the breakup of the USSR have been profound. Since 1990, poverty levels have grown overall, income inequalities have widened, and marginalized populations have become more vulnerable. In addition, migration, erosion of social networks and values, armed conflict, and the rise in high-risk behaviors such as selling sex, alcoholism, and injecting drug use have contributed to social disruption and resulted in deteriorating health status. The picture, however, has not been the same across all countries. Countries of the former USSR vary widely in terms of historical and cultural background, population homogeneity, income levels, and political processes. The countries of Central Asia have experienced significant economic crises and political instability, with dire public health consequences. Other countries, most notably Russia, have achieved political stability and benefited from its natural resources, particularly when oil prices were high, but have struggled to reform its public health system. Overall, compared with countries of the EU, health indicators have failed to improve in the former USSR. The pretransition health-care system of the former USSR has been largely inadequate in terms of the newly emerging demands made upon it, be the consequences of alcohol
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consumption and very high death rates among middle-aged men, the threat of multidrug resistance because of fractured connections between different elements of the tuberculosis control service, or a coherent evidence-based response to the HIV epidemic among injecting drug users. Access to care has been challenged by increasing levels of out–of-pocket payments as a share of total health expenditure, while budgetary funding has maintained extensive infrastructure over improving the quality of care. Patient access to care is less equitable than before the dissolution of the USSR in many countries. The vertical structures help perpetuate a narrow skill set among professional health-care workers. The ratio of doctors per capita in much of the former USSR is high, but the skills they hold are narrowly specialized, meaning that integrated, multidisciplinary patient-centered care remains a challenge to deliver. The health systems of the former USSR are, as are the countries’ political, economic, and cultural contexts, continually transforming beyond the initial socioeconomic shocks. For some, this change will be relatively painless. For others, it will be a painful process, affecting most acutely people who are already socially marginalized and living in poverty.
See also: Comparative Health Systems; HIV/AIDS and Tuberculosis.
References Atun, R.A., Samyshkin, Y.A., Drobniewski, F., et al., 2005. Barriers to sustainable tuberculosis control in the Russian Federation health system. Bull. WHO 83, 217–223. Balabanova, D., McKee, M., Pomerleau, J., Rose, R., Haerpfer, C., 2004. Health service utilization in the former Soviet Union: evidence from eight countries. Health Serv. Res. 39, 1927–1950. Balabanova, D., McKee, M., Mills, A., 2011. Good health at low cost 25 years on. What makes a successful health system? London School of Hygiene & Tropical Medicine, London. Available at: http://www.ghlc.lshtm.ac.uk/. Balabanova, D., Roberts, B., Richardson, E., Haerpfer, C., McKee, M., 2012. Health care reform in the former Soviet Union: beyond the transition. Health Serv. Res. 47 (2), 840–864. Balabanova, D., Mills, A., Conteh, L., Akkazieva, B., Banteyerga, H., Dash, U., et al., June 15, 2013. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 381 (9883), 2118–2133. Bonilla-Chacin, M.E., Murrugarra, E., Temourov, M., 2005. Health care during transition and health systems reform: evidence from the poorest CIS countries. Soc. Policy Adm. 39 (4), 381–408. Coker, R.J., Dimitrova, B., Drobniewski, F., et al., 2003. Tuberculosis control in Samara Oblast, Russia: institutional and regulatory environment. Int. J. Tuberc. Lung Dis. 10, 920–932. Danishevski, K., Balabanova, D., McKee, M., Atkinson, S., 2006a. The Fragmentary Federation: experiences with the decentralized health system in Russia. Health Policy Plan. 21 (3), 183–194. Danishevski, K., Balabanova, D., McKee, M., Parkhurst, J., 2006b. Delivering babies in a time of transition in Tula, Russia. Health Policy Plan. 21 (3), 195–205. European Observatory on Health Systems Policies, Health Systems in Transition Country Profiles 2006. http://www.euro.who.int/en/about-us/partners/observatory/publications/ health-system-reviews-hits/full-list-of-country-hits (accessed December 2015). Falkingham, J., 2004. Poverty, out-of-pocket payments and access to health care: evidence from Tajikistan. Soc. Sci. Med. 58, 247–258. Footman, K., Richardson, E., Roberts, B., Alimbekova, G., Pachulia, M., Rotman, D., Gasparishvili, A., McKee, M., 2014. Foregoing medicines in the former Soviet Union: changes between 2001 and 2010. Health Policy 118 (2), 184–192.
424
Russia and Former USSR, Health Systems of
Footman, K., Roberts, B., Mills, A., Richardson, E., McKee, M., 2013. Public satisfaction as a measure of health system performance: a study of nine countries in the former Soviet Union. Health Policy 112 (1–2), 62–69. Hopkinson, B., Balabanova, D., McKee, M., Kutzin, J., 2004. The human perspective on health care reform: coping with diabetes in Kyrgyzstan. Int. J. Health Plan. Manage. 219, 43–61. Jakab, M., Kutzin, J., 2009. Improving financial protection in Kyrgyzstan through reducing informal payments. Evidence from 2001–06. Policy Research Paper #57. Health Policy Analysis Unit (DFID/WHO), Bishkek. Kutzin, J., 2003. Health Expenditures, Reforms and Policy Priorities for the Kyrgyz Republic. Policy Research Paper 24. Health Policy Analysis Unit (DFID/WHO), Bishkek. Available at: http://www.hpac.kg/images/pdf/PERJKforPRP24.pdf (accessed May 2012, 2016). Kutzin, J., Cashin, C., Jakab, M. (Eds.), 2010a. Implementing Health Financing Reform: Lessons From Countries in Transition. WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, Copenhagen. Kutzin, J., Jakab, M., Cashin, C., 2010b. Lessons from health financing reform in central and eastern Europe and the former Soviet Union. Health Econ. Policy Law 5, 135–147. Lekhan, V., Nitzan-Kaluski, D., Jakubowski, E., Richardson, E., 2015a. Reforming the Ukrainian health system at a time of crisis. Eurohealth 21 (2), 14–17. Lekhan, V., Rudiy, V., Shevchenko, M., Nitzan-Kaluski, D., Richardson, E., 2015b. Ukraine: health system review. Health Sys. Trans. 17 (2), 1–153. Lewis, M., 2002. Informal health payments in central and Eastern Europe and the former Soviet Union: issues, trends and policy implications. In: Mossialos, E., Dixon, A., Figueras, J., Kutzin, J. (Eds.), Funding Health Care. European Observatory on Health Care Systems Series. Open University Press. Mackenbach, J.P., 2013. Convergence and divergence of life expectancy in Europe: a centennial view. Eur. J. Epidemiol. 28 (3), 229–240. Marx, F.M., Atun, R.A., Jakubowiak, W., McKee, M., Coker, R.J., 2007. Reform of tuberculosis control and DOTS within Russian public health systems: an ecological study. Eur. J. Public Health 17, 98–103. McKee, M., Healy, J., Falkingham, J., 2002. Health Care in Central Asia. Open University Press, Buckingham. McKee, M., 2001. The health effects of the collapse of the Soviet Union. In: Leon, D., Walt, G. (Eds.), Poverty, Inequality and Health. Oxford University Press, Oxford, pp. 17–36. McMichael, A.J., McKee, M., Shkolnikov, V., Valkonen, V., 2004. Mortality trends and setbacks: global convergence or divergence? Lancet 363, 1155–1159. Murphy, A., Mahal, A., Richardson, E., Moran, A., 2013. The economic burden of chronic disease care faced by households in Ukraine: a cross-sectional matching study of angina patients. Int. J. Equity Health 12 (38) (online). Parkhurst, J., Danichevski, K., Balabanova, D., 2005. International maternal health indicators and middle-income countries: Russia. Br. Med. J. 331, 510–513. Poletti, T., Balabanova, D., Ghazaryan, O., et al., 2007. The desirability and feasibility of scaling up community health insurance in low-income settings – lessons from Armenia. Soc. Sci. Med. 64 (3), 509–520. Preker, A.S., Feachem, R.G.A., 1995. Market Mechanisms and the Health Sector in Central and Eastern Europe. World Bank Technical Paper Number 293. The World Bank, Washington, DC. Rechel, B., McKee, M., 2005. Human Rights and Health in Turkmenistan. London School of Hygiene and Tropical Medicine, London. Rechel, B., Ahmedov, M., Akkazieva, B., Katsaga, A., Khodjamurodov, G., McKee, M., 2011. Lessons from two decades of health reform in Central Asia. Health Policy Plan. Rechel, B., Richardson, E., McKee, M. (Eds.), 2014. Trends in Health Systems in the Former Soviet Union. European Observatory on Health Systems and Policies/WHO Europe, Copenhagen. Rese, A., Balabanova, D., Danishevski, K., McKee, M., Sheaff, R., 2005. Implementing general practice in Russia: getting beyond the first steps. Br. Med. J. 331, 204–207. Richardson, E., Roberts, B., Sava, V., Menon, R., McKee, M., 2012. Health insurance coverage and health care access in Moldova. Health Policy Plan. 27 (3), 204–212. Roberts, B.1, Stickley, A., Gasparishvili, A., Haerpfer, C., McKee, M., August 2012. Changes in household access to water in countries of the former Soviet Union. J. Public Health (Oxf.) 34 (3), 352–359. Roberts, B., et al., 2012. The persistence of irregular treatment of hypertension in the former Soviet Union. J. Epidemiol. Community Health 66 (11), 1079–1082. Stickley, A., Koyanagi, A., Richardson, E., Roberts, B., Balabanova, D., McKee, M., 2013. Prevalence and factors associated with the use of alternative (folk) medicine practitioners in 8 countries of the former Soviet Union. BMC Complementary Altern. Med. 13 (83) (online).
Suhrcke, M., Rechel, B., Michaud, C., 2005. Development assistance for health in central and eastern European Region. Bull. WHO 83 (12), 920–927. Telishevska, M., Chenet, L., McKee, M., 2001. Towards an understanding of the high death rate among young people with diabetes in Ukraine. Diabet. Med. 18, 3–9. Thomson, S., et al., 2015. Economic Crisis, Health Systems and Health in Europe: Impact and Implications for Policy. Open University Press, Maidenhead, UK. UNAIDS, 2015. Gap Report UNAIDS. Geneva. http://www.unaids.org/sites/default/files/ en/media/unaids/contentassets/documents/unaidspublication/2014/UNAIDS_Gap_ report_en.pdf. World Health Organization Regional Office for Europe, 2015. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2015). World Health Organization Regional Office for Europe, 2006. European Health for All Database. http://www.euro.who.int/hfadb (accessed December 2007). Xu, K., Evans, D.B., Kawabata, K., Zeramdini, R., Klavus, J., Murray, C.J., 2003. Household catastrophic health expenditure: a multicountry analysis. Lancet 362 (9378), 111–117.
Further Reading Afford, C.W., 2003. Corrosive Reform: Failing Health Systems in Eastern Europe. International Labour Organisation, Geneva. Balabanova, D.C., Falkingham, J., McKee, M., 2003. Winners and losers: the expansion of insurance coverage in Russia in the 1990s. Am. J. Public Health 93 (12), 2124–2130. Coker, R.J., Atun, R., Mckee, M., 2004. Health care system frailties and public health control of communicable diseases on the European Union’s new eastern border. Lancet 363, 1389–1392. Davis, C., 1983. Economic problems of the Soviet health service: 1917–1930. Sov. Stud. 35 (3), 343–361. Field, M.G., Twigg, J.L. (Eds.), 2000. Russia’s Torn Safety Nets: Health and Social Welfare During the Transition. St. Martin’s Press, New York. Field, M.G., 1957. Doctor and Patient in Soviet Russia. Harvard University Press, Cambridge, MA. Field, M.G., 1999. Reflections on a painful transition: from socialized to insurance medicine in Russia. Croat. Med. J. 40, 202–209. Figueras, J., McKee, M., Cain, J., Lessof, S. (Eds.), 2004. Health Systems in Transition: Learning from Experience. European Observatory on Health Care Systems, Copenhagen. Krug, P., 1976. The Debate over the delivery of health care in rural Russia: the Moscow Zemstvo, 1864–1878. Bull. Hist. Med. 50, 226–241. Prager, K.M., January 29, 1987. Soviet health care’s critical condition. Wall Str. J. 28. Shishkin, S., 1999. Problems of transition from tax-based system of health care finance to mandatory health insurance model in Russia. Croat. Med. J. 40, 195–201. Tkatchenko, E., McKee, M., Tsouros, A.D., 2000. Public health in Russia: the view from the inside. Health Policy Plan. 15, 164–169. Twigg, J.L., 1999. Regional variation in Russian medical insurance: lessons from Moscow and Nizhny Novgorod. Health Place 5, 235–245.
Relevant Websites http://www.euro.who.int/observatory/Hits/TopPage – European Observatory on Health Systems and Policies Health Systems in Transition: Country Profiles (last accessed on 14.06.16.). http://www.euro.who.int/en/about-us/partners/observatory/publications/eurohealth – European Observatory on Health Systems and Policies, Eurohealth (last accessed on 14.06.16.). http://www.lshtm.ac.uk/ecohost/ – London School of Hygiene and Tropical Medicine, European Centre on Health of Societies in Transition (ECOHOST) (last accessed on 14.06.16.). http://www.cpc.unc.edu/projects/rlms/ – The Russia Longitudinal Monitoring Survey (RLMS) (last accessed on 14.06.16.). https://www.unicef-irc.org/– UNICEF Innocenti Research Centre, Florence, TransMONEE database (last accessed on 14.06.16.). http://www.worldbank.org/en/region/eca – The World Bank. Europe and Central Asia (last accessed 08.07.16.).