RESUMO
ÐACKGROUND: In the last two decades, health care systems (HCS) in the European countries have faced global challenges and have undergone structural changes with the focus on early disease prevention, strengthening primary care, changing the role of hospitals, etc. Russia has inherited the Semashko model from the USSR with dominance of inpatient care, and has been looking for the ways to improve the structure of service delivery. This paper compares the complex of structural changes in the Russian and the European HCS. METHODS: We address major developments in four main areas of medical care delivery: preventive activities, primary care, inpatient care, long-term care. Our focus is on the changes in the organizational structure and activities of health care providers, and in their interaction to improve service delivery. To describe the ongoing changes, we use both qualitative characteristics and quantitative indicators. We extracted the relevant data from the national and international databases and reports and calculated secondary estimates. We also used data from our survey of physicians and interviews with top managers in medical care system. RESULTS: The main trends of structural changes in Russia HCS are similar to the changes in most EU countries. The prevention and the early detection of diseases have developed intensively. The reduction in hospital bed capacity and inpatient care utilization has been accompanied by a decrease in the average length of hospital stay. Russia has followed the European trend of service delivery concentration in hospital-physician complexes, while the increase in the average size of hospitals is even more substantial. However, distinctions in health care delivery organization in Russia are still significant. Changes in primary care are much less pronounced, the system remains hospital centered. Russia lags behind the European leaders in terms of horizontal ties between providers. The reasons for inadequate structural changes are rooted in the governance of service delivery. CONCLUSION: The structural transformations must be intensified with the focus on strengthening primary care, further integration of care, and development of new organizational structures that mitigate the dependence on inpatient care.
RESUMO
BACKGROUND: The Russian Federation has introduced a vertical large-scale program of 'dispensarization' (Program) that includes health check-ups and screenings for the entire adult population. It is expected to improve the results of medical interventions and ensure health gains at a relatively low cost. The major research question: Does the design and implementation of the program meet the expectations? METHODS: We analyze regulatory acts and the literature on the design and the outcomes of the Program. Physicians' surveys and interviews are conducted to understand the capacity of primary care providers to meet the requirements of the Program, as well as the link between the early identification of new illnesses and their follow-up management, administration of the program, the barriers to its successful implementation. RESULTS: There is a substantial progress in the coverage of the population and increase in the number of identified illnesses. Some specific instruments of the Program implementation work well, others require more careful design and additional integrative and managerial activities. The capacity of primary care providers does not allow to provide high quality preventive services, as well as to ensure a continuum of preventive and curative work. The pattern of the Program administration facilitates its nation-wide implementation according to the unified rules, but makes it more difficult to account for the local conditions and limits the autonomy of professionals to choose specific population risk groups and a list of services. The interaction of providers in preventive activities is inadequate. CONCLUSION: The expectations of the Program are too high due to the inconsistencies in its design and implementation. The major lesson learnt is that the program like this should meet the capacity of primary care and be designed as a complex of interrelated activities to identify illnesses and provide their follow-up management.
