HEALTH MANAGEMENT EDUCATION IN RUSSIA IN THE CONTEXT OF HEALTH CARE POLICY AND REFORMS .

HEALTH
MANAGEMENT
EDUCATION IN
RUSSIA IN THE
CONTEXT OF
HEALTH CARE
POLICY AND
REFORMS .
Head, Centre for Social Studies, Institute of International Economic and Political Studies,
Russian Academy of Sciences, Moscow, Russia.

Haytham Al Fiqi Books: http://amzn.to/27nSCB9
2
Moscow 2003
Overview
The aim of this paper is to analyse the current state of health management education in
Russia. It is discussed in the context of
-- recent public sector initiatives and
-- health policy and management
Traditionally in Russian health care public sector plays a leading role that makes particularly
important the developments that take place in public administration as reflected in health care.
Such an approach is not common to Russian experts for the variety of reasons that will be also
examined further in this chapter.
Public administration in Russia: main contradictions and dilemmas.

3
The system of public administration in Russia is undergoing serious changes as a part of
market-oriented reforms in the country. The role and effectiveness of the state -- what the state
should do and how it should do -- it is analysed within the general discussion about the state's
role in economic and social development.
The major policy trend is minimisation of the role of the state-- especially as a direct
provider-- in social services, including health and increasing efficiency of the state
administration. Government is supposed to focus on core public activities and develop
mechanisms that give incentives to public officials to do their jobs better. It should be noted that
Russian scientists as well as policy makers are in general well acquainted with the discussions on
the issue carried on international arena, including such international organisations as OECD or
World Bank. But what is characteristic of Russian reforms is that very often the rhetoric is not
exactly reflected in practical measures: implementation has always been a weak point of Russian
policy process.
In fact in Russia the distinction between public administration and management is rather
blurred, especially in practice-- though the word "administration" is more often used to denote
"management in public sector" while management means "management in the private sector» it is
common to find position of manager in a public sector organisation. Such a distinction is more
strictly followed in educational programmes. Today in Russia there are many faculties and
programmes where student can obtain MBA or PA equivalent degree.1
In fact in Russia public administration covers civil service and state-owned organisations
which are particularly widespread in social sector.2 Civil servants are in a bit better position as
they are entitled to a certain privileges-- for example, better pensions. There is a discussion if
1 At present the higher education in Russia is reformed along the Western line-- Bachelor ( 4 years) /Master (5
years) degrees are being introduced everywhere.
2 The basic piece of legislation that regulates the activities of the civil servants is the Fundamentals of the civil
service adopted in 1995.

4
people working in state organisations in the social sector (doctors, teachers) should be treated as
civil servants and thus, get some privileges, too.
Managing a public bureaucracy in Russia is quite a challenging task because of
-- Low financing (state organisations are usually under financed both in terms of the planned
budgetary appropriations and the actual amounts received)
-- low salaries ( low morale). There is a special salary scale for the staff of the state
organisations. Today the government promotes the reform of the system and wants to reintroduce
separate scales for each branch (education, health care, science, etc.)
All the problems mentioned above apply to the state health services.
Health care system in Russia: from the Semashko model to compulsory health
insurance.
In Russia as an integral part of the USSR health care was financed and provided by the
state ( so-called Semashko model) when practicing of private medicine was a rare exception.
While significant achievements of the system are generally recognised some major drawbacks are
also well known. It is generally admitted that the Semashko model that showed positive
outcomes in times when the principal aim of health care was to fight infectious diseases could
not ensure the proper level of the treatment of chronic illnesses which share in the morbidity
structure increased. The health care system continued to develop "in-width" (setting up new
policlinics and hospitals, training more professionals, etc.) while increasing its efficiency in the
circumstances of the decrease of resources apportioned by society for health care under the
conditions of a slowing down economic growth did not attract a proper attention of the Soviet
leaders as well as researches (Korchiagin,1990; Preker and Feachem,1994; Sheiman,1995;
Stains,1999 ).
Transition to a market economy and decentralisation of decision making inevitably entailed
a reform in health care. It has been strategically carried out through the introduction of

5
compulsory health insurance (CHI) and the decentralisation of financing and management of
health care.
The principals of CHI and mechanisms of their implementation were laid down in a few
juridical documents to include the 1991 Law on CHI. The following arrangements were
introduced:
✓ CHI with universal coverage;
✓ enterprises and organisations were bound to contribute to health insurance for the
employed, local administrations were to pay for those not employed;
✓ basic CHI programme of CMI including a minimum set of medical services provided by
the CMI system had to be adopted at the federal level and regional programmes could not
be less in their scope than the federal one;
✓ individuals as well as organisations could participate in voluntary health insurance;
✓ the system of CHI Funds -- the Federal fund of CHI and regional funds of CHI -- were to
be set up as independent state non-commercial credit and monetary agencies. They were
to ensure the comprehensive character of CHI, the achievement of social justice and
equality within the CHI system as well as its financial stability. The CHI funds were to
accumulate contributions to CHI then transferring resources to health services either
directly or via special health insurance companies (HIC) as independent non-profit
organisations. The main functions of HICs were to conclude contracts with health
services (hospitals, polyclinics); to reimburse them for medical services provided for the
insured; to defend interests of the insured and to control the quality of health care.
By the year of 2000 the Federal Funds of CHI, 90 regional funds of CMI with 1129 branches
and 362 HIC were set up in Russia.
The CHI funds system in its present form has a strongly pronounced territorial character:
regional funds of CHI are independent bodies but not branches of the Federal fund of CHI as it

6
is, for example, the case with the Pension Fund.3 Second, the funds of CHI collect contributions
from enterprises and organisations, on one hand, and regional administrations, on the other hand.
The CHI contribution of enterprises and organisations was fixed at 3,6% of payroll divided
between The Federal fund (0.2 percent) and a territorial fund (3.4 per cent) covering the
employed only and not including their dependants. The contributions of regional authorities are
to cover the health services for those not employed.4
By the end of 1990s is became evident that introduction of CHI failed to bring about
evident positive results, namely improvement in assess or quality of medical services. On the
contrary, the quality and scope of medical services provided as well as health status of population
continue to decline. Hospitals and polyclinics suffer from the lack of equipment and medication.
People run into the same problems of the access to and quality of medical services provided in
the places, which in many cases need major renovations and re-equipment. In quite a number of
hospitals a patient has to provide medication, food and even bed linen for oneself.
Development of the CHI system itself has also encountered serious problems. First, it is
characterised by extreme irregularity that has created, in particular, a grave problem of using
insurance policies issued by a regional fund to get medical treatment outside its area. Besides by
2000 only about 30 per cent, or 8210 health services to include 5649 hospitals, 1900 primary
care/policlinics and 661 dental clinics joined the CHI system.
As a result three CHI models have been taking shape in the course of the health reforms. In
some regions reforms develop as envisaged by the legislation in force. Regional finds accumulate
the resources and conclude contracts with HICs which act as insurers and directly deal with
health services. Thus, CHI money is received by the latter through HIC.
3 Social funds in Russia include four out-of-budget funds: The Pension Fund, The Employment Fund, The Social
security fund and funds of CHI.
4 In accordance with the new Tax Code starting from 2000 CHI contributions are collected by the tax inspections as
a share of a new unified social tax

7
In 15 regions only funds of CHI function that collect money and act as insurers. HICs have
not been set up there and health services receive money from funds of CHI or their branches
directly. In the rest of the regions a combined system has been formed -- funds of CHI and their
branches as well as HICs act as insurers. Their shares substantially vary depending on a region.
Second, the collection of payments to CHI is in a quandary. Enterprises as well as regional
administrations often do not fulfil their commitments. In many regions health authorities are
unwilling to make contributions for the economically non-active population. According to the
Federal fund data, the share of payments by the employers amounts to about 60 per cent of all
CHI receipts whereas contributions for the not employed made about 26 per cent. Arrears to CMI
system were 48 mln roubles worth by the beginning of 1998.5
At present as average over 65 per cent of resources for health care needs are coming from
budgets of different levels, including 80 per cent from local budgets, the rest of 35 per cent being
the share of CHI. It should be noted that there are substantial regional variations in the share of
CHI that fluctuates from 2 per cent in the Saratov region to nearly 78 per cent in the Samara
region.
The reforms in health care were not accompanied by relevant organisational changes. In fact
new structures -- CHI funds-- were mechanically implanted into the old administrative system
which remained practically intact. It could not but led to springing up of a conflict. the plurality
of players in the health system five main being the Ministry of Health, regional and local health
authorities, the federal and regional funds of CHI, health insurance companies and health
services does not add to effectiveness of health care.
Relations between the CHI agencies and regional and local health authorities have not been
forming easily. Both sides have been fighting for supremacy in the health care system and often
cannot come to mutual understanding and find a compromise. The structure of health care system
5 The official data about the financial status of CHI system are so insufficuent that it hampers independent research.

8
itself has not improved: the number of the notorious beds which became the banner of the
criticism of the Soviet model has not in fact substantially lessened and no principal changes for
the better in primary health care has occurred. What has reduced is the number of medical
personnel -- it is less now but mainly due to the fact that wages/salaries in health care system are
still one of the lowest in the country. As a result, many medical professionals has to occupy two
positions simultaneously which enables them to get two salaries but definitely lead to work
overload and poor quality of medical treatment.
The main innovation that reforms declared in primary health care was introduction of the
institution of the general practitioner. But despite the positive experience of the functioning of
this institution in other countries its introduction in Russia is likely to bring about many problems
their solution being subject to considerable additional investments.
The main problem with the health reforms underway in Russia is that they were not well
thought conceptually and their implementation was not thoroughly prepared. For example,
regional administrators are entitled to define the amount of their contributions themselves taking
into account the structure of population and its health status while those of enterprises and
organisations are fixed by the federal legislation and a fine is imposed for non-payment. Though
the dependency ratio is increasing the contribution of regional authorities make only 31 per cent
of those paid by enterprises and organisations. Regional administrators have been, in practice,
cutting down expenditures on health care by paying CHI contributions for those not employed
from their budgets thus simply redistributing budget means.
As a result, the necessity to introduce certain changes into health care system is recognised
even by the proponents of CHI. But at this stage it is not very clear what will happen as different
further reform proposals are discussed. But it is likely that the general trend will continue.
Health management education
Today the importance of health management education is acknowledged by virtually
everyone in Russia. In all statements made by the health official of various status -- from

9
members of Duma to Minister of Health and heads of CHI funds-- it is stressed that there is a
need to improve the quality of management in the health system as organisation and management
of health care services provide a vital link in the efficient delivery of quality care. Such
statements result from the increased recognition that competent management is essential in every
organisation and program at every level. Thus, changes in organisation and financing of health
care have created a need for well-qualified people who can manage health services in new
realities and who received management training in cost constraint, quality assurance and access
to health care.
At present there are about 4 mln people working in health care (in the system of Ministry of
Health), among them 680000 doctors and 1,6 mln nurses and other medical staff, or 45 doctors
and 100,2 other medical staff per 10000 of population. The ratio is 1/2,5.
Traditionally people who occupy managerial positions in health care system are almost all
doctors. In fact, health care system in Russia is managed by physicians. There is a very strong
believe in medical profession that only doctors can manage health services. It is reinforced by the
fact that Minister of Health and other senior health officials, members of Parliament, who work
in Health Committee -- they are all doctors. The dominant culture of health services has been
static for years.
Most of doctors work in the public sector and are state employees and salaried. The salary of
health administrators depends on the size of the institution which is measured as a number of
beds for hospitals of various types and number of doctor's positions for policlinic and other
primary care health services. Several qualification groups -- 5. Doctors working in dangerous
conditions are entitled to extra payments, for example, tuberculosis-- 15 percent, psychiatric-- 25
per cent, leprosarium-- 30 per cent
Health service administrative positions include:
-- chief physician (head);

10
-- deputy chief physician;
-- chief nurse;
-- head of departments, laboratories, units
There are several characteristics features of health management education in Russia.
-- In general, medical education is under a strict control of the medical profession. There are
59 medical institutes, universities and academies in Russia, that are controlled by the Ministry of
Health. There are three basic stages of medical education in Russia:
-- graduate degree (6 years of study);
-- postgraduate professional training (2 year either ordinatura or internatura)
aspirantura (post graduate studies to apply for research degree);
-- professional retraining (very often in a new speciality).
Every year about 100000 people graduate from medical universities. Starting from 1994 the
admission rate is fixed in accordance with planned need in doctors of various specialities-- about
21200 every year all together, including 19800 full time. There is also a system of so-called
targeted admissions -- for specific regions and programmes -- separate competition. The
competition to enter medical universities is quite high-- about 5 people per place as average.
Besides medical schools there are also several universities that traditionally have medical
faculties (the Moscow State University named after Lomonosov and University named after
Patris Lumumba in Moscow). Medical faculties are also open in some other Russian
humanitarian universities (Petrozavodsk, Chebiksari, Nalchick, Saransk, Yakutsk, Tula,
Novgorod). But they mostly offer biological specializations, psychology, social work in health
and health economics.
The Ministry of Health with cooperation of the Ministry of Education develops the
curriculum. There is a special group on high medical and pharmaceutical education in Russia the

11
Ministry of Education that adopts educational standards in medical education (UMO-- teaching
and methodological unit).
-- There are two basic types of health management programmes according to the degree
awarded.
a) Graduate training in health services administration is a relatively new phenomenon in
Russia. In fact there was no any graduate programme in health management for people to be
appointed as health managers until mid 1990s. Doctors usually had no special managerial
training, except that they were required to take re-training courses-- as all other state employees--
every 5 years.
The first degree-granting programme was established only in 1996 -- Faculty of health
management in Moscow Medical Academy named after Sechenov (MMA). It is an equivalent of
2-year ordinatura, which trains health managers.
The program includes 6-month placement with one of the health services or local health
administrations. The faculty also provide retraining courses for health managers and for lecturers
in health management. Actively use funds provided by international organisations-- TACIS. The
program teaches such subjects as public health, health policy, health economics and statistics,
strategic management, marketing, health law, etc.
b) There are a number of retraining courses that are designed for those who currently hold
administrative positions. After finishing training most of them will return to work at their
original institutions.
It should be noted that formal professional education for the management of health services
is well established in most developed countries. Master's degree is recognised as the ideal
qualification for administrative practice. Administrative specialisations for clinicians reflect
increasing efforts to ensure competence of those who manage scare recourses.

12
-- Since top level administrators in health services delivery system are MD, health
management programs are physically and organisationally located in medical schools under
administrative control of the Ministry of Health.
However, at present a number of non-medical universities – both humanitarian and
polytechnics– offer health management programs. But it is virtually impossible to tell how many
such programs do exist. Though the general feeling is that the number of such programs has a
tendency to grow.
One of the explanations of thus phenomenon can be that medical schools formally do not
grant management degrees– according to diploma students graduate as “social hygiene and
organization of health care” specialists. Only this year Ministry of Health plans to introduce a
new degree – “public health and management”. Probably this is to stress that they are doctors
first. As to non-medical universities, the situation seems to be the opposite. They usually
introduce health management as a specialisation within management or public administration
degrees. This means that student graduate first of all as managers.
-- Ministry of Health uses it authority to keep the leading positions of doctors in health
management. For example, it issued a special decree (n337/1999), stipulating what medical
qualification should managers have in order to be appointed to administrative positions in health
services (see table below)
Administrative position Medical qualification required
chief doctor social hygiene and organisation of health
care* or any clinical speciality
deputy social hygiene and organisation of health care
or any clinical speciality

13
head department clinical speciality (main profile of the
department)
* social hygiene and organisation of health care includes therapy, surgery, trauma and
orthopaedic, endocrinology and physiotherapy.
-- Changes in health management produced a good chance for nurses to raise their status of
in the Russian health care. Now they can study – after finishing nursing colleges– at medical
universities for 4 years and get graduate degrees in management. In 2000 in Russia 22 medical
universities offered students such a degree (full time, part time and distant learning format). 947
graduate nurses (managers) graduated from Russian medical universities for the period of 1996
to 2000. Every year about 250 nurses (managers) get their degrees. 748 nurses-managers are
working for health authorities and in health services. But the problem is that graduate
nurses/managers can not take administrative positions of doctors' managerial hierarchy-- they can
work as chief nurses or directors of nursing homes or hospices, or – subject to 5 year work
experience– move up hierarchy within nursing.
-- Position of doctors as managers results in a difficulty to reconcile managerial and
professional culture. Doctors have always regulated assess to health care-- they have always
taken decisions as to whether patients should be treated and with what level of intervention. So
called clinical freedom when a doctor makes a decision in the best interests of the patient.
Professional are guided in their activities first of all by the interests of their clients while
managers have to think about the interests of organisation as a whole and very often society at
large. In health care this “conflict" is even more evident as there is a need for both professional
and managerial expertise to take decisions in health care to ensure quality, assess and efficiency.
Russian health managers are professionals who perform management functions. This means
that they typically perform clinical work-- from the Minister of Health, who travels on a regular
basis from Moscow to SPetersburg to operate patients in SPetersburg military hospital to heads

14
of the departments or units in hospitals or policlinics. They had to combine general managerial
tasks with the management of clinical activities and physicians.
Physicians had little if any management training to assume this responsibility. Their
expectations are established by means of an education that is hospital, technology and specialty
centred. Thus, balancing managerial and professional functions puts additional pressure on
physicians. For example, one of the studies on social portrait of health managers carried out in
Krasnoyarsk showed that health administrators lack knowledge of how to deal with people.
-- Professional and managerial career are interlinked in Russian health care. Administrative
position is to a large extent a form of recognition of doctor’s talents and qualifications. Doctors
are salaried employee of a state-run organisation, and managerial position is high and means
moving up the career ladder. Today administrators need not only specific managerial knowledge
but also the ability to be proactive and risk taking. There fore becoming managers doctors, on
one had, get high salary and more prestige, and, on the other hand, need to change some of their
approaches to people and work.
Tentative conclusions
Managing changes that will result from emerging public policy will be the most significant
responsibility of health services managers. This will require broad knowledge of issues and
options, and new approaches to management.
At present there are three major dilemmas in health management education in Russia.
First, there is a tension between doctors' monopoly on health administration, on the one
hand, and the promotion of managerial culture in the society that emphasise the increased role of
management in the new conditions of decentralisation, promote and raise the status of managers.
This raises the problem of whether we need physician manager or full time general manager/
public administrator with no clinical functions? Here cost considerations should also be taken
into account as it is very expensive both in terms of time and money the train doctors-- do we
need to use them as managers diverting from performing clinical functions?

15
The complexity of the challenge and the consequences for community mandate purposeful
preparation for a career in health services management. Previous training in medicine, nursing is
useful but not sufficient. Individuals with clinical backgrounds need in-depth knowledge of
management and social sciences as they apply to health. Those with management training need
systematic knowledge of medicine and health. As a rule medical schools do not teach
management and management schools do not teach health. The way out might be establishing
partnerships between them in training managers for health care. But at present this seems to be a
challenging task as medical profession evidently tries to preserve its ultimate control in health
care.
Second, the state monopoly in health care – both in financing and delivery– is being
questioned in Russia. There are already a number of private clinics in the country and there is a
tendency for their increase in numbers. Charging fees for service has also become quite common
even in the state health services which means that they looking for patients who can pay. What
model of management-- public or private-- should Russia adopt in promoting health management
education? Or, probably, health management education should be diversified according to the
needs of a particular organisation? Anyway, programs should combine the content that is
essential to successful management in the health sector.
Third, there are different layers of health management (Ministry of health-- chief doctors--
heads of departments). It makes sense to vary accordingly health management degrees. At this
stage I think health management education should also address the needs of health policy makers
as there is no other opportunity for them to get any knowledge in policy making by means other
then health management programs.
The major weaknesses of the study can be explained by the lack of information. It turned out
to be very difficult-- if possible at all-- at this stage to
✓ To evaluate the quality of teaching, and

16
✓ To follow graduates career. It is unclear if graduates have a chance to use their knowledge
at their workplace and whether they really occupy managerial polis ions in the health care
system.
REFERENCES
Sheiman I.(1995). New methods of financing and managing health care in the Russian
Federation. Health Policy 32; 167-180.
Staines V.S. (1999). A health sector strategy for the Europe and Central Asia region. The
World Bank: Washigton D.C..
Preker A.S., Feachem R.G. (1995). The market mechanisms and the health sector in Central
and Eastern Europe. World Bank technical paper N293. World Bank: Washington D.C..
Labour markets and social policy in Central and Eastern Europe: transition and beyond
(ed. by N.Barr). (1994). NY: Oxford University Press.
Grigorieva N., Tchoubarova T.(1997). Health status of population: a need for a new
approach. Eurohealth vol 3, N 2 (Summer).
Grigorieva N.(1998). Provovoye obosnovaniye realizatchii cjnzeptczii ob okhrane zdorov'ya
naseleniya Rossii. In T.I.Zaslavskaya(ed.) Kuda idet Rossiya?..Transformaziya sotzial'noy speri i
sotzial'naya politika. M.: Delo.; 349-355
Dzlieva G.H., Solov'eva O.G. (1996). OMS-- osnovnoye napravleniye reformirovaniya
rossiyskogo zdravookhraneniya. Zdravookhraneniye, n 5; 14-29.
Korchiagin V.(1990). Ekonomicheskiye reformi v zdravookhranenii. Voprosi ekonomiki
,11:13-22.
Nazarova I.B.(2000) Reformi zdravookhraneniya: za i protiv. Zdravookhraneniye, 5;.29-36.
Razzvitiye OMS v Rossiyskoy Federazii:1993-1998.(1999). Analitichesky material. M.,
Federal'ny Fond OMS.
Shishkin S.V. (1995). Metamorphozi rossiyskogo zdravookhraneniya. Voprosi ekonomiki ,
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