Health system reform in Russia: The finance and organization perspectives

In April 1993, the president of the Russian Federation signed an amended health insurance law (HIL) designed to change fundamentally the structure of health system finance, organization, and management according to basic principles common to most OECD nations. The legislation provides for the separation of system functions as follows: a. funding of care; b. organization and management, or purchasing, of care through "insurance companies" or sickness funds; and c. provision of care. While the first function remains primarily "public," so as to ensure universal access and equity, it is anticipated that the two other functions, especially the third (provision of care), will eventually become decentralized and "non-governmental," possibly private, so as to promote production efficiency and client satisfaction. The separation of functions and the changes in ownership and management of care revolutionize the system. Nevertheless, despite the conceptually attractive features of the HIL, major issues remain to be addressed before successful implementation of the law can be achieved. These issues relate to the overall economic and institutional environment needed to support the legislation; policy-making and orientation of care; resource adequacy necessary for health objectives and equity; and denationalization of services. These issues should be addressed in conjunction with immediate measures needed to make the legislation operative, such as eligibility, relationship between social insurance and budgetary resources, and development budgets.