HEALTH POLICY IN RUSSIA. Part III. Irina V. McKeehan Campbell COLUMBIA UNIVERSITYCOLUMBIA UNIVERSITY, INTER-PR, INC.

Before the HIA could be implemented, an insurance infrastructure had to be developed.

On December 25, 1992, a law was proclaimed "On Insurance contributions to the Fund of Social Insurance of the Russian Federation, to the State Employment Fund, and to the compulsory Health Insurance of citizens for the First Quarter of 1993."

On February 24, 1993, this legislation was followed by

The public health care funds of the 1991 HIA were redefined in 1993 as part of government social insurance, which provided compulsory health insurance, financed as a percentage of employee wages.

In removing mandatory insurance from the private market, the 1993 Health Insurance Act followed the Canadian model of guaranteeing universal access through public health insurance.

The breakup of the socialist health bureaucracy was accelerated with the separation of administrative and financing functions in the independent, nonprofit structure of CHI funds.

Seven interest groups were specified as part of the administrative boards of the CHI at the local level: consumers, trade unions, medical professionals, health insurance companies, the central bank, representatives from federal health funds, and legislators.

The 1993 revisions of the Health Insurance Act emphasized medical social security in guaranteeing universal access and a basic comprehensive benefits package in the compulsory insurance component, which was equally available to the employed, unemployed, and indigent through the CHI.

The health funds were designed to function as fiscal intermediaries between consumers and providers, encouraging the growth of insurance companies and the gradual privatization of health care, thereby differentiating and restricting government activities.

The exact mechanisms of the transition to private ownership of the health care delivery system were left ambiguous in the 1993 revision of the Health Insurance Act.

The 1993 Health Insurance Act constructs an array of incentives for the development of private ownership of a state-controlled health care system; it also assures that health care is a human right rather than a function of income and privilege.

There is the danger that mandatory public insurance will lead to lesser care for the greater number, whereas voluntary private insurance will lead to luxury level care for the smaller elite.

Progress has been made by the Russian Federation in recognizing health as intrinsically valuable, not just a convenient ideological platform or instrumental component of government economic policy.

The health market is not a free market in any nation; everywhere it is a mix between the private and public sectors.

The mix between the public and private health sectors is converging among most industrialized democracies to include several common elements.

The differentiation of management and finance from the actual provision of health care exists to some degree in all efficient health systems.

The Russian Federation has incorporated several of these structural elements into the Health Insurance Act of 1993, trying to balance the issues of health care quality and equity for the public with the lack of private ownership of a self-financing medical industry.

The current provisions of the HIA do not address the issue of private ownership of hospitals, clinics, and other medical facilities.

The health insurance crisis of the 1990s placed the problem of health reform legislation and preventive health policy on the agenda for nations everywhere.

The proposed Clinton Health Security Act argued for the right of each American to have access to health by eliminating risk-based insurance.

There is, however, a noticeable lack of even a philosophical commitment in the legislation to emphasize primary care and preventive programs in either the public or private sector. Setting national priorities for health promotion and disease prevention requires attention to the following:

Health reform legislation needs to organize a uniform empirical data collection system to track the progress towards the preventive goals outlined above.

Planning, enacting, and implementing legislation are functionally as far apart as changing beliefs and changing behavior. The enactment of health reform legislation exemplifies which beliefs about the health care system need to be modified.

The monitoring of health status indicators, as the gold standard for assessing the quality of health care outcomes, provides the rationale for legislative institutionalization of the set of beliefs underlying health reform.

In the late 1990s, the health insurance system which Russia tried to implement since 1993 has been largely a failure.

The WHO, the European Union and the World Bank recommended, in 1999, that Russia revert to its state health service from insurance medicine, acknowledging that a mistake was made in advising such a sudden change in the financing and organization of health care (UNDP, 1999; WHO, 1999).

The health insurance funds rely on a 3.6 percent tax on all payrolls, supplemented by local funds for those not working. The money is allocated to insurance companies that contract with local hospitals and clinics for care.

A catch-22 has been created for both patients and medical facilities: under health insurance, staff salaries, even if token like $20 per month, were paid with some regularity, although hospital and polyclinic budgets have decreased by half.

It was estimated that 17% of all health care spending occurred through additional unreimbursed cash payments.

The WHO representative in Moscow, Mikko Vienonen, agreed in 1999 that WHO and the World Bank health policy urged upon Russia were erroneous.

Russia no longer has universal health care, but it also lacks a competitive and effective health insurance system, almost a decade after being legislated into existence.