The fragmentary federation: experiences with the decentralised health system in Russia.
This paper for the first time, provides evidence on the decentralisation trends since the breakdown of the USSR, reporting the results of case studies undertaken in six regions of Russia (Samara, Tver, Tula, Chelyabinsk, Sverdlovsk and Moscow oblasts) to describe the organisation of health care financing, regulation and delivery. It shows that while there is a common model of health system (with the exception of Samara, where an innovative model has been achieved), there are many minor variations. The study confirms the limited scope for action by Federal authorities, but also shows that the power vested in the regional governments is more limited than was previously thought. Instead, the municipalities (rayons) emerge as important bodies, as they own the facilities in which much of the routine health care is delivered and, both directly and indirectly, by virtue of their contributions of insurance premiums for the non-working, provide a substantial amount of health care financing. The study demonstrates the complexity of the Russian health care system and identifies the widespread absence of mechanisms that might be used to bring about much needed change.
Health Policy and Planning, 21 (3,: 183-194 pp.