Building health promotion into health care reform in Russia.

The health care system of the former Soviet Union, despite serious flaws, did provide the basis for community health activities, and for mandatory immunization and periodic health examinations for which primary care physicians were responsible. Since 1991, a new system of mandatory health insurance has been put into place. Health care funding has decreased substantially, owing to economic conditions. However, there is not yet widespread acceptance either of the strong association between personal behaviour and health consequences, nor of the importance of individual responsibility for one's health. To summarize, efforts at health promotion and disease prevention in Russia face numerous barriers: severe financial constraints owing to the general economic situation; social upheaval with loss of previous constraints on behaviour; cultural characteristics that include fatalism and encouragement of heavy alcohol and tobacco consumption; lack of acceptance of individual responsibility for health; lack of role modelling by the medical community; lack of critical appraisal of benefit and cost-effectiveness for preventive interventions; low priority for health care, and for prevention specifically. Disease prevention and health education must be built into the reformed health care system, to promote health for the Russian population.