HEALTH CARE FINANCING AND MANAGEMENT SYSTEMS IN THE REGIONS OF THE RUSSIAN FEDERATION
Ed. by S. Shishkin. Authors: G. Besstremyannaya, A. Zaborovskaya, V. Chernets, S. Shishkin. Moscow, 2006

The appendix contains brief descriptions of the health care financing and administration systems in 88 subjects of the Russian Federation, as well as more detailed descriptions of the experience implemented in the more innovative regions.

Summary

Significant differences exist in the various subjects of the Russian Federation regarding organization of governmental financing and management for the health care system. In order to systematize the data about such differences the Independent Institute of Social Policy has developed a database on the organization of health care financing and management in the different regions of Russia. This database is one of the constituent parts of the database named "The implementation of the health care reform in the subjects of the Russian Federation", which has been developed through the support provided by the Ministry of Health and Social Development of the Russian Federation and by the WHO/CIDA Program "Health care policy and stewardship in Russia". The Federal Fund of compulsory health insurance has provided support in developing the database.

The developed database is located at the following websites: http://www.healthreform.ru and http://zdrav.socpol.ru. It contains information about the various components of the regional systems dealing with health care financing and management:

Public financing for health care:

• the amount of public spending for health care;
• the share of funds pooled by compulsory health insurance (CHI) in the public financing for health care;
• the list of insurers taking part in the CHI system and the methodes of their financing;
• the types of health care facilities financed through the CHI system;
• the provider payment methods used for out-patient and in-patient care in the CHI system;
• the number of medico-economical standards used for the purpose of health care provider reimbursement.

Health care management:

• the mechanisms of coordination of the policies implemented by the regional health care administrative body and by the regional CHI fund;
• the mechanisms of coordination of the regional and municipal policies;
• the use of computer technologies in health care management;
• the mechanisms of regulating supplies of medication;
• the methods of price regulation for chargeable health care services .

The sources of information were the information references filled in by the administrative health care bodies in the subjects of the Federation and by the territorial CHI funds.

The current publication presents the results of the analysis of regional differences in the organization of health care financing and management, which had been conducted on the basis of information contained in the abovenamed database. A system of characteristics for comparative evaluation of level of development of public health care financing and management mechanisms was elaborated. On this basis the regions were typified according to the level of development of certain characteristics pertaining to the systems of financing and management, and integral typologies were also developed.

The appendix contains brief descriptions of the systems of health care financing and management in 88 subjects of the Russian Federation, as well as more detailed descriptions of the corresponding innovations in the 8 most innovative regions.

The analysis of the existing data has led to the following main conclusions:

For all the main components of the financing and management systems in health care there exist significant differences between the subjects of the Russian Federation (the regions):

• despite the budget reform which has been carried out, there remains a noticeable territorial inequality in the financial coverage of the citizens' rights to receive health care services;
• though the share of funds pooled by the CHI system in public financing has been increasing during the recent years, nevertheless there remain significant regional differences in the level of its development; financing of the health care providers from regional CHI system is taking place according to different rules: there are 7 main provider payment methods used for out-patient care, and 6 provider payment methods used for in-patient care;
• a difference can be noted between the regions in the diversity and complexity of the mechanisms of management which are used for interaction between the health care management bodies with the regional CHI funds and local administration bodies;
• mechanisms of governmental regulation as regarding the provision of chargeable health care services, ensuring drug supplies and pricing are used differently in the regions;
• the level of use computer technologies in the regional systems of health care management varies significantly.

The present state of the systems of health care financing and management in the subjects of the Russian Federation is the result of transformation of the once integrated system of administrative management and budget financing due to the processes of decentralization of governmental authorities and significant expansion of the competence of local authorities, implementation of the CHI system, change in the conditions of management for the health care facilities. This transformation took place in various ways in the different regions. Correspondingly, the modern system of organization of the health care management is characterized by significant regional differences.

The existing regional models of health care financing and management bear a transitional character. Their diversity reflects the variety of regional socioeconomic and political peculiarities of the transition from the centralized governmental system with planned economy to a decentralized state with market economy. In this sense the large number of such models has a system-forming character for the existing Russian health care system. At the same time, the differences between the regional models reflect to a larger extent the different conditions of distribution funds between public health care facilities than the territorial peculiarities related to providing for efficient functioning of the sector. In the majority of the subjects of the Russian Federation the regional systems of CHI do not ensure the stability of financial conditions for the activity of the purchasers of health care services - the insurers. The mixed mechanisms of provider financing from budget and CHI system motivate health care facilities towards reproduction of the existing structure regarding the volumes of provided care and the cost-is-no-object type of management. That is why the system of health care financing is in need of reforming, and the frameworks of acceptable diversity of the regional models of health care financing should be significantly narrowed.

Despite a prolonged delay at the federal level with the carrying out of the health care reform which has been imminent for a long time, institutional changes are noticeable at the regional level in the organization of health care financing and management. According to the data for the years 2002-2004, the innovations have been implemented in approximately one third of the subjects of the Russian Federation. In ten of the regions they were related to different components of the system of management and financing, while in the others individual innovations were carried out. The regions characterized by most innovative activity are the Irkutsk oblast, the Krasnodarsky krai, the Novosibirsk oblast, the Perm oblast, the Primorsky krai, the Samara oblast, the Tula oblast.

The innovations in the area of health care financing affect the following components of the financing systems:

• the forms of interaction of insurers with insurants in the CHI system;
• mechanisms for monitoring of the insurers' activity;
• provider payment methods;
• use of medico-economical standards for the purpose of health care provider reimbursement;
• mechanisms of quality control of the health care services;
• information systems;
• mechanisms of ensuring medication supplies for the health care facilities.

The innovations in the organization of health care management primarily include:

• multilateral agreements between regional and municipal bodies;
• development of the forms of coordinative management (councils, etc.).

The tendencies of the observed changes are different. On the one hand, there is noticed a strengthening of centralized control and development of mechanisms for administrative resource distribution within the regional health care systems, on the other hand - a development of coordination and collaboration, both vertically and horizontally, and development of institutes for co-measurement of costs and results.

The mechanisms of health care financing are better developed in the regions which possess a larger volume of available resources of different types (high gross regional product, large size of population, innovative potential or the region, more international technical assistance projects in the area of health care organisation). At the same time, progress in development of regional health care systems is not determined by a large volume of financial resources in the region. The leaders from the point of view of developing the mechanisms of health care financing and management are the regions with an average per capita gross regional product: the Voronezh oblast, the Krasnoyarsk krai, the Novosibirsk oblast, the Rostov oblast, the Samara oblast, the Sverdlovsk oblast. A more important factor is the existence of political commitment to support the carrying out of the reforms, an administrative potential, previously gained experience of organizational and managerial innovations.

The analysis which has been conducted shows clearly an actual influence that the level of development of the mechanisms for health care financing and management has on the progress related to the structural changes in the system of providing health care services and on the final results of its activity - the indicators of the health status of the population.

The better the mechanisms of health care financing and management are developed, the more successful will the restructuring of the outpatient/polyclinic and hospital care be. In particular, it leads to a larger scale of decreasing the number of beds, and to increasing the number of general practice physicians working in the region. The higher the share of funds pooled by CHI system in the total amount of financing for health care, the less number of beds is being used. The more differentiated the tariffs for health care services are in the CHI system, the larger was the scale of decreasing the excessive number of beds.

The share of funds pooled by CHI system in the governmental financing for health care in the region is positively correlated with the life expectancy of its citizens. The more developed the mechanisms of regional health care management are, the less morbidity increase is noted in the region.

The prevalence of innovations in the area of health care financing and management at the regional level and their character prove that the Russian health care system as a whole possesses the ability to develop, implement and disseminate organizational, economic and managerial innovations in a decentralized way.

Nevertheless reforms of health care financing and management are required at the federal level. At the same time, the federal reforms should leave sufficient space for regional reforms: the regions should have certain possibilities to choose the content and rates of introducing the innovations.

The federal reforms should be tailored according to the groups of regions.

The leading group from the point of view of development of health care financing and management systems includes 6 regions (the above mentioned Voronezh oblast, the Krasnoyarsk krai, the Novosibirsk oblast, the Rostov oblast, the Samara oblast, the Sverdlovsk oblast). In these regions it is expedient to conduct pilot testing of the complex mechanisms of financing and management:

• apportionment of the general practice physicians as independent subjects of management;
• fund-holding of primary health care providers;
• sharing of the financial risks between the CHI funds and the insurers;
• participation of the insurers in the development and implementation of the programs of restructuring of health care services;
• transformation of certain governmental and municipal health care institutions into public autonomous not-for-profit organizations;
• implementation of new forms of salary of medical workers related with results of their activity.

At the same time it is necessary to ensure direct participation of the abovenamed regions in the development of federal normative documents which regulate the implementation of the appropriate pilot testing, and also to provide them with wide opportunities of independent determination and correction of specific elements in the mechanisms that are being tested.

In the group of "advanced" regions (24 subject of the Federation) it is expedient to place the priority upon the carrying out of the following changes:

• concentration of the governmental resources allocated for the financing of providing health care services in the CHI system;
• pilot testing of the programs for supplementary health insurance financed in part by the government and in part by the population (in regions with a high level of gross regional product and population income);
• development of systems of medico-economic standards and their use when determining the tariffs of reimbursement for health care services through CHI;
• development and implementation of programs aimed at the restructuring of health care services;
• development of the institute of general practice physicians;
• transfer of the majority of the budget health care facilities into the form of autonomous institutions;
• implementation of new forms of salary of medical workers related with results of their activity.

In the course of conducting these changes it is advisable to allow the regions certain opportunities for introducing changes into the implemented innovations.

In the regions which can be rated as "average" (24 regions) it is possible to conduct pilot testing of certain types of new financing and management mechanisms, however it is advisable to implement changes on a large scale only after their pilot testing in the first two groups of regions. Possible variations of the implemented mechanisms should be clearly defined in advance.

In the lagging regions it is advisable to implement only those mechanisms which have already undergone successful pilot testing. The priority areas for implementation are the following:

• the method of reimbursement for hospital care per completed case of treatment;
• the method of reimbursement for primary health care services based on the per capita norms;
• the forms of salary of medical workers related with results of their activity.