Russia began reforming its system of primary health care in the 1980s, replacing the old Soviet model of highly specialised doctors based at policlinics with one of integrated general practice centred on general practitioners (GPs). The process has been hampered by serious obstacles, however, and a number of changes will be required if the reform is to be successful.

For the past 15 years, most eastern and central European countries have been discarding the former Soviet system of health care, an element of which has been replacing the old model of narrow specialties with one of general practice. In Russia, new legislation which was to form the basis of the reform was put into effect in 1992 and a programme was developed to train GPs, which began that year. It is estimated that about 90,000 GPs will be needed to serve the nation effectively, based on a ratio of one doctor for every 1,500 people.

Research by the Health Systems Development Programme at the London School of Hygiene and Tropical Medicine looked at progress in the implementation of primary care reform and found that it has been slow and difficult. At the time of the study only 2,500 GPs had been trained, yet the study showed that returning trainees experienced major hurdles when putting into practice what they had been taught. They faced resistance from senior doctors, infrastructure and equipment were in short supply, and they were hindered by unchanged financing systems.

Findings include the following constraining factors:

• In policlinics, conditions were very difficult for newly trained GPs and due to poorly allocated funding they often lacked basic equipment and had no transport to visit patients at home.
• Federal legislation was vague and there were no specific local provisions – GPs faced boundary disputes with specialists as the scope of general practice lacked clear definition.
• GPs working in policlinics found that their extended role was not recognised and soon slipped back into the old model, providing superficial care for a high number of patients.
• GPs faced a lack of recognition and support from health administrators and resistance from policlinic specialists and hospital physicians, who felt undermined by their role.

The research highlights the need for an approach that is system-wide – while some elements of primary care have been set up; many other elements have been ignored. Newly trained GPs have not been given the chance to put their new skills into practice. Although the new model has proved popular with patients, the persistence of the old system has demoralised new GPs.

If the reform is to be successful, the following changes are essential:

• Supportive legal and regulatory frameworks must be put in place at the federal level so that regional authorities can develop and apply policies at the local level.
• A human resource strategy must be set up to improve staff retention and motivation, with system-wide incentives created in line with the goals of reform.
• Investment must be made in resources, including modern technology, to support the change.
• Support must be sought from municipalities as they can help facilitate change. 

Source(s):
‘Implementing general practice in Russia: getting beyond the first steps’, British Medical Journal 331, pages 203-207, by Andrey Rese et al, 2005
HINARI subscribers can access the full-text article here. Full document.

Funded by: LSHTM Health Systems Development Programme, UK Department for International Development (DFID)

id21 Research Highlight: 31 March 2006

Further Information:
Dina Balabanova
Health Systems Development Programme
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
United Kingdom

Tel: +44 (0)20 7927 2929
Fax: +44 (0)20 7637 5391
Contact the contributor: dina.balabanova@lshtm.ac.uk

Health Systems Development Programme, London School of Hygiene and Tropical Medicine, UK

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