Genuine federalism in the Russian health care system: changing roles of government.

The reforms that have affected the Russian health care system since the breakup of the Soviet Union, principally those in the general administration of the Russian Federation, have suffered from inconsistency and the absence of a strategy. The various reforms have caused a shift from a national health system characterized by highly centralized management and control, typical of the totalitarian uniform state, to a highly decentralized but fragmented multitude of state systems. Each of these systems is relatively centralized at the local level and run by local administrations with limited government infrastructure and experience. The role of government in the emerging system, and in particular the role of the federal government, remains ill defined. As a result, there is a grave risk that the Russian health care system may disintegrate as a national system. This undermines (a) the prevailing universal and fairly equitable access to care, (b) stabilization of the system following a long period of transition, and (c) the long-term reform that is required to bring the Russian health care system up to par with the health care systems in other developed countries. A rapid transition to a genuine federal health system with well-articulated roles for different levels of government, in tandem with implementation of the 1993 Compulsory Health Insurance System, is essential for the stabilization and reform of the Russian health care system.