Russia's Soviet legacy healthcare system: progress and prospects

As aging populations, escalating healthcare costs and the pervasive rise of preventable chronic disease change the face of healthcare globally, in Russia, the Soviet legacy continues to shape the responses of the local healthcare system to these challenges.

The prioritization of expensive hospital-based care, the neglect of primary care, the emphasis on treatment rather than prevention, the over- and misuse of doctors, the under-utilisation of nurses, the low remuneration of all healthcare professionals, and an outdated approach to medical training represent major obstacles to Russia’s plans to improve the health of its population. In this context, an emerging crisis in the supply, training, and role of doctors has now become an accepted health policy challenge.

Progressing the Soviet legacy system

This is the legacy of the Soviet period. The enduring perception of the physician as a relatively inexpensive resource has stubbornly remained throughout the post-socialist period. Until very recently, the average salary of the physician has hovered around 25-30% above the overall economy average, while the equivalent figure in the pre-2004 EU countries is closer to 300%. The affordability of this labour has been a strong driver both for increasing the number of physicians and for avoiding modernizing the roles of nurses and other health workers.

Much of Russian primary care remains delivered through the so-called “district physicians”, who work as salaried employees in multispecialty polyclinics. These doctors refer approximately one-third of their first contact patients to specialists¹. The corresponding figure for most European countries is around 10-15%². During the 1970s, an attempt was made to ‘support’ the district physicians by increasing the number of outpatient specialists in the polyclinics. However, this merely reinforced the proliferation of very narrowly defined specialists and patients have grown to increasingly mistrust the district physicians because of their limited area of clinical expertise. In sum, while there are many primary care physicians, the relatively minor role they play undermines the comprehensiveness, continuity and integration of care, and is not appropriate for a country health profile increasingly grappling with widespread chronic and multiple morbidities.

The sustained reliance on the district physician model has also reduced the impetus for a shift to a General Practitioner (GP) based model. The number of GPs in 2013 was only 0.7 per 10,000 residents compared to an average of 5.7 in the post-2004 EU. Figure 2 confirms these observations.

Addressing the acute shortage of Russian GPs

Following from this, the incentives to become a GP are much lower in Russia than in the EU countries and it is no surprise that the average percentage of students that choose to become GPs in Russia is dwarfed by the equivalent figures in other European countries.

The question of how to address this acute shortage is paramount and attention naturally turns to the recruitment and training of Russian physicians. In Russia, training is relatively short and contained, taking 7-8 years, including medical school, a one-year internship or a two-year residency. Beyond qualification, the concept of continuous professional development is a relatively new one in Russia. The general requirement for physicians is to upgrade their qualification every 5 years through a course that lasts between 3 and 12 weeks. Until recently, this training has been provided by special postgraduate training institutions, and physicians were not able to select medical facilities in which to retrain. The drawbacks of inadequate medical education and postgraduate training along with a limited tradition of continuing professional development and low remuneration are demotivating for current, as well as future, physicians.

In tackling these problems, the government has sought to address the enduring perception of physicians and nurses as under-valued and over-worked resources in three ways:

• First, by increasing salaries of physicians and nurses
• Second, by acknowledging that the physician-population ratio should be lower while the number of nurses should increase
• Third, by implementing reform of medical education and training. Developing practical skills, re-equipping university clinics, embracing health technologies, strengthening the qualification and remuneration of trainers, increasing the residency term from 2 to 5 years and finally, allowing physicians to retrain within medical facilities.

While laudable and ambitious, this reform agenda could have a bigger chance of tackling the problems of skill shortages and a fragmented healthcare system, by addressing:

• The model of district physicians
• The shortage of GPs in primary care facilities
• The need to shift the emphasis of care from treatment (in hospitals) to prevention (through primary care and other means)
• The requirement to disperse key roles from physicians to nurses
• The integration of e-healthcare and digital technologies into the broader policy framework
• The regional inequalities that prevail across the vast Russian territory.

Twenty-five years after the end of the Soviet period, the desired shift towards an integrated framework of preventative primary healthcare remains a long way off and, in the current economic climate of low oil prices and economic sanctions, the healthcare financing gap which has persisted for decades will not be bridged any time soon.

More optimistically, these public-sector funding constraints will open multi-sector opportunities for e-healthcare to develop. As middle- and high-income earners increasingly turn to paid medical services and adopt care expectations prevailing in more advanced economies, providers will be forced to raise standards, improve efficiency and incorporate new global developments in prevention, diagnosis, and treatment. Innovations are already emerging to address these dynamics in Moscow and St. Petersburg. With the right policy environment, the potential efficiency gains, particularly in a country as large as Russia, are sizeable and the vision of ‘empowerment’ outlined by the Future Health Index may be less elusive than it at first appears.

¹ Potapchik EG, Selezneva EV, Shejman IM, Shishkin SV. 2011. Mediki o processemodernizaciizdravoohranenija. Zdravoohranenie, № 1

² Wilson A, Windak A, Oleszczyk M, Wilm S, Kringos D. 2015. The delivery of primary care services. In: Building primary are in a changing Europe. Kringos D, Boerma W, Hutchinson A, Saltman R. (eds.) The European Observatory on Health Systems and Policies. Copenhagen. WHO.