Universal Health Coverage in Russia: Extending Coverage for the Poor in the Post-Soviet Era

Over the past two decades Russia experienced a significant increase in state-financed entitlements for health care through the Program of State Guarantees for Medical Care (PSG). The PSG, which is underpinned by the Constitution was an important element of the social contract implemented by the State on the back of rapid economic growth during the 2000s. The PSG is a universal program with uniform benefits paid for through a single national pool. The PSG was accompanied by significant supply side investments to develop a multi-level service delivery system, substantially increase tertiary care provision, strengthen the diagnostic capacity of medical facilities and reduce geographic variations in funding and services. This case study examines what the increase in state financed entitlements for health meant for coverage of the poor in Russia, using the health sector in Russia in the early 1990s as the starting point. The economic and political transformations of the early 1990s resulted in a significant deterioration in health outcomes and financial protection. Although health outcomes have improved, they continue to lag behind that of comparator countries. Large PSG related investments and reforms during the 2000s supported the achievement of health gains and moderated the reversal of trends during the fiscal crisis. Fiscal redistribution has been used to increase resource allocation to less well-off areas. Increased public spending on hospital care helped improve access to inpatient care for the poor, particularly the elderly. Increased investment in diagnostic equipment at outpatient care facilities is associated with increased access to tests and services, albeit only in major cities. A push to reallocate spending towards primary care increased access to both physicians and services in rural areas. Limited PSG coverage for outpatient drug purchases means that OOP drug payments remain one of the biggest threats to financial risk protection. To further deepen and expand coverage for the poor, there is a critical need to narrow the divergence between PSG’s de jure and actual coverage. In principle, the PSG provides a uniform benefits package that all Russians are entitled to under the Constitution. In practice, underfunding and a lack of clarity over the benefits package lead to implicit health care rationing through inadequate access to good quality health care services and affordable drugs and supplies. Additional fiscal space for health is needed and health policy must make more effective use of available resources. Expanding coverage for outpatient drugs and strengthening primary care are immediate priorities.