This paper addresses the major developments in primary care in the Russian Federation under the evolving Semashko model. The overview of the original model and its current version indicates some positive characteristics, including the financial accessibility of care, focus on prevention, patient lists, and gatekeeping by primary-care providers. However, in practice these characteristics do not work according to expectations. The current primary-care system is inefficient and has low quality of care by international standards. The major reasons for the gap between the positive characteristics of the model and the actual developments are discussed, including the excessive specialization of primary care, weak health-workforce policy, the delay in the shift to a general practitioner model, and the dominance of the multispecialty polyclinic, which does not prove advantageous over alternative models. Government attempts to strengthen primary care cover a wide range of activities, but they are not enough to improve the system and cannot do this without more a systematic and consistent approach. The major lesson learnt is that the lack of generalists and coordination cannot be compensated for by the growing number of specialists in the staff of primary-care facilities. Big multispecialty settings (polyclinics in the Russian context) have the potential for more integrated service delivery, but to make it happen, action is needed. Simple decisions, like merging polyclinics, do not help much.

Objectives:-evaluate the level of fragmentation/integration in the Russian Federation health care -explore tools to strengthen integration with the focus on economic incentives Methods: survey of physicians (1700 in 3 regions of Russia), review of the literature Results:1) the conceptual framework is suggested for the evaluation of health services delivery integration, as well as around 50 indicators for teamwork, coordination and continuity of care. 2) Physicians report low level of teamwork, coordination and continuity of care in Russia. 3) Bundled methods of payment (prospective payment for both outpatient and inpatient care, including repeated admissions) is the most immediately viable approach to encourage integration of providers. In Russia there is a good evidence of the method known as 'policlinic as fundholder' (fundholding method). It creates incentives for policlinics to plan all stages of service delivery, cooperate and communicate with hospitals, refer patients to the best providers, expand activities to avoid aggravations of chronic cases.

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In the late 1980s, it became clear that poor outcomes of the Russian health system were caused not only by underfunding but also by inadequate management of health care. Some features of the system led to great inefficiency in medical care provision and an irrational structure of medical care. The recognition of this fact has intensified the search for new methods of finance and management. The underlying idea of health care reforms in Russia is to weaken providers' dominance, to make them more responsive to consumer preferences, and to change the structure of medical care. The main developments of the reform parallel the reforms in Western countries. These are primarily the separation of finance and provision of medical care, with the shift from an integrated to a contractual model of relationships between payers and providers. But the specific characteristics of the health care situation, primarily the great underfunding and the absolute dominance of state-owned medical facilities, make the reform in the Russian health sector more radical. This paper highlights the issues of the current and planned developments in the Russian health sector. After presenting the main characteristics of the current health systems, it addresses economic experiments which are underway in several regions of the new Russian Federation. They are designed to introduce elements of market relations into a highly bureaucratic system. The main features and the impact of the experiments are discussed. Then the new model of finance, which is based on a transition from tax-financed to the health insurance system, is presented.

Objectives:-evaluate the level of fragmentation/integration in the Russian Federation health care-explore tools to strengthen integration with the focus on economic incentives Methods: survey of physicians (1700 in 3 regions of Russia), review of the literature Results: 1) the conceptual framework is suggested for the evaluation of health services delivery integration, as well as around 50 indicators for teamwork, coordination and continuity of care. 2) Physicians report low level of teamwork, coordination and continuity of care in Russia. 3) Bundled methods of payment (prospective payment for both outpatient and inpatient care, including repeated admissions) is the most immediately viable approach to encourage integration of providers. In Russia there is a good evidence of the method known as 'policlinic as fundholder' (fundholding method). It creates incentives for policlinics to plan all stages of service delivery, cooperate and communicate with hospitals, refer patients to the best providers, expand activities to avoid aggravations of chronic cases.

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While many countries have increased the opportunities for patient choice of provider, there is debate to what extent this has had positive effects on efficiency and quality of healthcare provision. First, some conditions should be met to exercise such choice, of which the most important is the provision of reliable data on providers' performance to both patients and physicians as their agents, as well as increasing primary health care (PHC) providers' involvement in realization of patient choice. Second, expanding patient choice does not always lead to efficient allocation of resources in a healthcare system. This article explores these controversial developments by using empirical evidence from the Russian Federation. It shows that choice indeed has value for patients, but there are many areas of inefficient choice, which leads to misallocation of healthcare recourses. Thus, health policy in this area should be designed to ensure a reasonable balance between objectives of expanding choice and promoting more efficient organization of healthcare provision. Political rhetoric about unlimited patient choice may be useless and even risky unless supported by well-balanced programmes of supporting and managing choice.

Background The concentration of health care providers is a growing process in many countries, including Russia. There is a general expectation that larger medical entities can better promote the process of service integration. Purpose This paper explores the impact of health provider concentration on service delivery integration through the indicators of teamwork, coordination and continuity of care in outpatient and inpatient medical facilities. These developments in Russia are compared with international experience. Methods National and international literature on health services concentration and integration is reviewed; statistical analysis is based on Russian national data, WHO and OECD databases; a sociological survey of Russian physicians and interviews with managers of medical facilities are used to evaluate the value of integration. Results The review of international trends indicates a growing process of mergers to form large hospital and physician-hospital systems, particularly in the USA. Enhanced clinical and administrative integration is usually seen as the logical outcome of concentration. However, growing international empirical estimates demonstrate a controversial impact of concentration on quality of medical care, unit cost (per patient) and integration of care. In Russia, the establishment of consolidated health systems is coupled with an increase in the average size of hospitals, while the number of free-standing providers has substantially decreased. The effect of concentration in the country is also controversial. There is some evidence of its positive impact on restructuring service delivery and the accessibility to some services, but the surveys of physicians don’t demonstrate improvement in the organization of service delivery, nor closer links between providers. Surveys of providers don’t provide evidence of teamwork, coordination and continuity of care in consolidated settings. Conclusion There are many deeply rooted barriers to integration in Russia, of which the most important is the lack of clear objectives of providers mergers. The major lesson learnt is that in the country with limited financial resources, decisions on provider concentration should be carefully justified with the focus on the specific integrative activities. National health policy for integration should be a major pre-condition for the positive impact of concentration on integration.