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Risk Management and Healthcare Policy 2018:11 209–220
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REVIEW
open access to scientific and medical research
Open Access Full Text Article
http://dx.doi.org/10.2147/RMHP.S168399
The evolving Semashko model of primary health
care: the case of the Russian Federation
Igor Sheiman
Sergey Shishkin
Vladimir Shevsky
Center for Health Policy, National
Research University Higher School of
Economics, Moscow, Russia
Abstract: This paper addresses the major developments in primary care in the Russian Federa-
tion under the evolving Semashko model. The overview of the original model and its current
version indicates some positive characteristics, including the financial accessibility of care,
focus on prevention, patient lists, and gatekeeping by primary-care providers. However, in
practice these characteristics do not work according to expectations. The current primary-care
system is inefficient and has low quality of care by international standards. The major reasons
for the gap between the positive characteristics of the model and the actual developments are
discussed, including the excessive specialization of primary care, weak health-workforce policy,
the delay in the shift to a general practitioner model, and the dominance of the multispecialty
polyclinic, which does not prove advantageous over alternative models. Government attempts
to strengthen primary care cover a wide range of activities, but they are not enough to improve
the system and cannot do this without more a systematic and consistent approach. The major
lesson learnt is that the lack of generalists and coordination cannot be compensated for by the
growing number of specialists in the staff of primary-care facilities. Big multispecialty settings
(polyclinics in the Russian context) have the potential for more integrated service delivery, but to
make it happen, action is needed. Simple decisions, like merging polyclinics, do not help much.
Keywords: health policy, primary health care, general practitioner, Semashko model
Introduction
Primary health care (PHC) is the first point of contact with health care where most
preventive and curative health care needs are satisfied. This generalist care is focused
on the person as a whole, instead of only one specific organ or health problem.1,2 There
is evidence that countries with strong PHC systems have relatively higher indicators
of health outcomes.3 Strengthening this sector is an important strategy for improving
service delivery, including decreasing avoidable hospital admissions and emergency
visits,4 and enhancing patient satisfaction. This is an important element of health policy
throughout the world.5
Russia and most other postcommunist countries have inherited the Semashko
model of primary care (named after the first Minister of Health in the USSR – Nikolai
Semashko), dominated by publicly owned medical facilities, salaried health workers,
large providers of PHC, and an exceptionally high degree of governmental administra-
tion. This system provides universal access to care, and thus has substantially improved
the health status of the population relative to the starting point of its implementation
in the late 1920s.6,7 However, in the USSR, health care was heavily underfunded and
had a number of noticeable problems with the dominance of inpatient care, inefficient
Correspondence: Igor Sheiman
National Research University Higher
School of Economics, 20 Myasnitskaya
Ulitsa, Moscow 10100, Russia
Tel +7 495 612 0142
Email igor.sheim@g23.relcom.ru
Journal name: Risk Management and Healthcare Policy
Article Designation: REVIEW
Year: 2018
Volume: 11
Running head verso: Sheiman et al
Running head recto: Semashko model of Russian Primary Care
DOI: http://dx.doi.org/10.2147/RMHP.S168399
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Sheiman et al
service provision, and weak incentives for providers.8,9 These
problems have promoted the search for a new health-finance
and -provision model.
After the collapse of the USSR in 1991, Russia introduced
a social health-insurance system and started service-delivery
restructuring with a focus on downsizing hospital capacity
and moving patients to outpatient settings. Strengthening
PHC was declared a priority in all the strategic documents of
the transition period. However, the actual development of this
sector has been slow and inconsistent. Contrary to postcom-
munist Central and Eastern European (CEE) countries, Rus-
sia developed its own system of primary-care development,
emphasizing highly consolidated service provision in big
multispecialty facilities and the dominance of public owner-
ship. General practice is still in its infancy, while an attempt
has been made to compensate for this with a growing number
of specialists in primary-care settings. Currently, PHC is a
complex mix of inherited and new institutions, which together
make a model that is an alternative to the prevailing European
model of self-employed GPs or group practices.2
International literature on PHC in Russia is limited. The
papers available state that the country has a strategy of incre-
mental reforms.10,11 Some papers have explored the priority
of PHC in the overall health care system, and concluded that
actual monetary support has lagged behind political declara-
tions. Specialty care still prevails in Russia and other former
Soviet countries.12 Most authors conclude that the Semashko
model has remained practically untouched,10–12 although this
is not entirely true. This model has evolved significantly, but
not always positively.
Another body of literature has compared PHC interna-
tionally. The Primary Health Care Activity Monitor in Europe
(PHAMEU), which includes nine CEE countries, concludes
that the traditional division between “East and West” is
disappearing. Estonia, Lithuania, and Slovenia are among
the countries with the strongest PHC systems in Europe.2
A number of papers address the specific characteristics of
PHC transformation, including GP task profiles13–15 and the
growing variety of primary-care practices.16
This analysis does not cover Russia or other former Soviet
Union countries with similar health systems, such as Belarus,
Ukraine, Kazakhstan, and Armenia. This is a serious gap in
the literature, since these countries have a specific model of
PHC. This paper fills this gap. Our objectives are twofold:
first, to highlight the characteristics and developments of the
Russian PHC model, and second, to look at the outcomes of
this model from an international perspective and discuss their
strengths and weaknesses. An overview of key primary-care
characteristics is provided, followed by a presentation of the
major problems of the sector and recent efforts to ameliorate
them, and then a comparison of the efficiency and quality of
primary care internationally. We conclude with a discussion
of this model and lessons learnt.
The analysis is based on a review of the literature on
PHC developments, as well as the materials from the Rus-
sian federal and regional ministries of health. Recent plans to
strengthen this sector are also evaluated. Statistical analysis
is based on national data. World Health Organization and
Organization for Economic Cooperation and Development
(OECD) databases are used to compare economic conditions,
workforce developments, and efficiency. The comparison of
the comprehensiveness of PHC is based on the methodology
of the PHAMEU2 and a survey of 171 primary-care physi-
cians from 14 Russian regions. A list of questions from the
European report was distributed through the Russian social
network Vkontakte in May 2016 and then supplemented
with face-to-face interviews with 20 physicians in Moscow
polyclinics. The sample of respondents was developed with
specific selection criteria. As such, a descriptive analysis was
supplemented with a survey and interviews.
The authors are deeply involved in developing the national
health care strategy in the capacity of independent experts.
This paper summarizes the current approaches to strengthen
PHC. Our major motivation to produce this paper is to share
information on recent developments in Russia with policy
makers in countries that have delayed major reforms of
primary care and are now looking for the ways to catch up
with the European mainstream. Another motivation is to
revisit the Semashko model (which is usually criticized in
the literature) and to compare its original design with the
actual implementation.
Major characteristics of the Russian
primary-care system
The major principle of the Semashko model is the financial
accessibility of care. This has not been questioned in modern
Russia. All citizens are entitled to free health care. However,
the health system is heavily underfunded. Public health fund-
ing is currently only 3.5% of GDP, while in European coun-
tries it is 6%–10%.17,18 Limited financial resources undermine
the principle of financial accessibility. People often have to
pay formally and informally. The share of private funding
is 39% of total health care expenditure against an average
24% for Europe.17,18 The share of outpatient care is much
lower than for inpatient care. Most visits to the doctor and
diagnostic tests are free.
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Semashko model of Russian Primary Care
The governance of PHC is centralized at the level of
regional governments. This is seen as a way to consolidate
resources and mitigate imbalances across communities in the
region (There are 85 regions in the country with the popula-
tion ranging from 500,000 to 12 million. Each region has
10-20 local communities [municipalities]). The downside is
that the role of communities is insignificant: most decisions
are made by regional health authorities and territorial social
health-insurance funds that act as major purchasers of care.
Attempts to decentralize governance in the 1990s were not
successful, given serious underfunding and the geographic
inequity of economic capacity.19
A major provider of PHC is the multispecialty, publicly
owned polyclinic. This is usually much bigger than traditional
general practices in Western countries. The capacity of poly-
clinics varies from 100 to 120,000 people served in big cities
to fewer than 15,000 in small towns and rural areas. PHC for
adults and children is separated, with separate adult and child
polyclinics operating in urban areas. District therapists serve
adults and district pediatricians serve children (together they
are further referred to as district physicians [DPs]). GPs or
family doctors are relatively rare.
Polyclinics provide primary and specialty care for uninfec-
tious diseases and preventive services. The “district service”
is a structural unit of polyclinics with a staff of DPs, GPs, and
nurses. In the original Semashko model, DPs were the sole
providers of primary care, but currently specialists provide a
greater volume of care in polyclinics. Depending on the size
of the policlinic, there are five to 20 categories of specialists
providing most of the polyclinic’s services: 60%–65% of
visits.20 Most polyclinics have diagnostic units (eg, laborato-
ries, endoscopy) and units that are responsible for preventive
services and health promotion. Patients of polyclinics have
access to a wide range of services under the same roof.
People can choose a polyclinic, and most choose the pro-
vider closest to their place of residence. Patients enrolled in
a polyclinic form the patient list. DPs and GPs have smaller
catchment areas, while specialists serve all the enrollees of
the polyclinic. The patient list is an important characteristic
of the system. It existed in the original Semashko model, and
has not been questioned since. Polyclinics are responsible
for their enrollees’ health care on a long-term basis, which is
usually regarded as the indicator of strong primary care.2,10,15
According to federal regulations, DPs and GPs act as
“gatekeepers” and refer patients to specialists and hospitals.
This is also a characteristic of a strong PHC system, since
it ensures the coordination and continuity of care provided
at various levels of service delivery.2,10,15 The gatekeeping
function was in the design of the original Semashko model,
but currently it is not strictly followed in many regions. As
the following section shows, patients can see some special-
ists directly without a referral from primary-care physicians.
The Semashko model considers prevention, a major area
of primary care and the scope of preventive activities, has
been increasing. A recent innovation is a large-scale federal
program of “dispensarization” (a term from the original
Semashko model), which includes a wide range of checkups
and screenings and covers around a third of the population.
Each polyclinic enrollee is supposed to have them once
every 3 years. Program monitoring is based on the number of
detected cases of disease, including those at an early stage.21
A special characteristic of the Semashko model is the
“method of dynamic dispensary surveillance”. This method
presumes that every detected case of a serious disease is sub-
ject to a certain set of protocols, including planning curative
activities, documenting them, ensuring the required number
of contacts with DPs and specialists, a monitoring process,
and outcome indicators. The design of these protocols (they
were developed in the late 1960s) has some resemblance to
the modern programs of chronic-disease management that
are common in many Western countries,22,23 although they do
not include some elements of these programs, such as multi-
specialty groups of providers, distant monitoring of patients’
status, and bundled payment. This method was relatively
well developed in the USSR, but in the decades since it has
given way to the large-scale detection of new cases under the
program of “dispensarization” without clear follow-up targets.
The original Semashko model was based on total public
ownership of medical facilities and on medical workers
as employees. The situation has changed over the last two
decades. The number of private providers has increased sub-
stantially, mostly in the area of outpatient specialty care. But
their share of the total number of physician visits remains low
– 6.4%. Most physicians in private facilities are employees,
similarly to public facilities. The bulk of services provided by
private facilities is for out-of-pocket payment. The involve-
ment of private providers in the provision of publicly funded
care is limited to around 4%.24 The principles of patient lists
and gatekeeping do not extend to private settings: they operate
without catchment areas, do not have any commitments for
the constant management of cases, and most contacts do not
require primary-care referrals. GPs are equally uncommon
in private settings.
PHC in Russia is much broader than was presumed by
the original concept (as mostly generalist care). It is also
broader than in most Western countries. The concept of
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Sheiman et al
“extended primary-care composition” advocated by some
international scholars10 in Russia has reached the form of
multispecialty polyclinics. The federal law “On the basics of
health protection in the Russian Federation” (2011) concep-
tualized extended primary care by introducing the concepts
of primary physician care and specialized primary medical
care. The former is provided by DPs and GPs, the latter by
polyclinic specialists.
These concepts mean that the borders of PHC and out-
patient care practically coincide, while in Western countries
a distinction between outpatient and primary care remains
even in extended PHC systems: outpatient care is significantly
wider in scope and totally different in function and clinical
areas. Specialists do neither act as gatekeepers and coordina-
tors of care, nor do they provide comprehensive care focused
on the patient as a whole. Most importantly, specialists are
not responsible for the ongoing surveillance of patients;
rather, they provide episodic care. Even when specialists are
first-contact physicians, all other characteristics of PHC are
absent or limited.
The extended composition of PHC is the major distinc-
tion of its organization in Russia. The other basic features of
the system – financial accessibility, patient list, gatekeeping,
preventive-care orientation, ongoing surveillance of serious
cases – can be regarded as indicators of a strong PHC sys-
tem. Contrary to many criticisms of the Semashko model
of primary care, it was originally well designed by modern
standards. However, Russia currently faces a lot of problems
with the implementation of this design.
Current activities to strengthen
primary care
The government is attempting to solve PHC problems in the
following directions:
1. overcoming the shortage of DPs and improving their
competence;
2. improving polyclinic performance;
3. strengthening preventive activities;
4. closing the gap between urban and rural PHC;
5. increasing the remuneration of primary-care physicians.
Overcoming the shortage of primary-
care physicians and improving their
competence
The worldwide tendency of specialization of the health
workforce and a decrease in the share of generalists25,26 is par-
ticularly strong in Russia. This tendency started in the USSR
in the 1970s and continues today. Most clinical functions of
DPs have been delegated to specialists, and the number of
the latter has increased to a level where specialists outnumber
other doctors in such polyclinics as PHC facilities. DPs have
turned into the internal medicine specialists dealing with the
simplest cases and losing their core position in PHC.27
A shift to a GP model was declared in the 1990s, but
then gave way to reservations about this model. It is seen as
appropriate mostly for rural areas and small urban neighbor-
hoods. The actual implementation of this shift has been very
inconsistent, contrary to most CEE countries, which have
trained enough GPs to replace DPs during the 8–10 years of
transition.13 The number of GPs in Russia in 2014 was only
0.7 per 10,000 residents compared to an average of 8.7 in the
pre-2004 EU and 5.7 in the post-2004 EU.17 The total number
of primary-care physicians (DPs and GPs) per resident has
been decreasing. This decrease over the last 10 years has not
been compensated for by the insignificant increase in the
number of GPs. The latter still have a marginal role in PHC.
They account for only 13% of the total number of primary-
care physicians (Figure 1).
Regulation of the supply of health workers in Russia is
poorly focused on primary care. Medical universities have
substantial discretion in setting the structure of undergradu-
ate and postgraduate training. A study of medical university
capacity indicated that in 2016, only 20% of universities
had general practice as a subject in undergraduate medical
training and only 70% had postgraduate positions in general
practice, while in European countries all medical schools
have this subject for undergraduates and postgraduates.2 The
proportion of students that choose to become GPs in Russia
is <5%, while the average figure for 31 European countries
is 17% and in some countries (eg, France) is 35%–45%.28
Our estimate of the shortage of DPs is 33%, and for district
pediatricians 12%. The estimate is based on the standards of
the enrolled population – 1,700 for district therapist and 800
for district pediatrician. To meet these standards, the country
needs 90,600 DPs, but the current number is only 60,600.
The physicians available have to hold more than one position
and are thus overburdened. The average number of residents
served by district therapists is 2,630 patients, which is about
50% higher than the target (1,700 residents) established by
the Russian federal Ministry of Health (MoH).
Apart from the inadequate number of DPs, their task
profile is limited by Western standards. To measure the
comprehensiveness of care (ie, competence to treat a set of
diseases), we rely on the indicators that were used by the
PHAMEU in 31 European countries2 and the aforementioned
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Semashko model of Russian Primary Care
survey of Russian DPs. A major indicator of PHC compre-
hensiveness is the percentage of total contacts with patients
handled solely by primary-care physicians without referral
to specialists. Russian DPs were asked to make this estimate
for their own practices. The average share for all respondents
was 70%. This is a very optimistic estimate. However, it is
substantially lower than in most European countries, where
85%–95% of contacts are handled by general practitioners
without the involvement of specialists.2 Other indicators of
comprehensiveness are also relatively low in Russia.29 This
can be interpreted as a result of the excessive specialization
of PHC and the inadequate training and professional devel-
opment of DPs.
The government is looking for ways to overcome the
shortage of DPs and strengthen their clinical capacity. The
strategy of health-workforce development includes a shift to
2–5 years’ postgraduate training, continuous postgraduate
training to replace periodic training, the development of a new
system of accreditation, and strengthening the role of medi-
cal associations in accreditation.30 These are the activities
planned for the medium term. The immediate action (which
started in 2017) is loosening the requirements to work as a
DP. Most medical graduates are accredited for practicing
as DPs without postgraduate training. The new approach
may mitigate the shortage of DPs in the short run, but at the
expense of the quality of primary care. No other country fills
vacancies of primary-care physicians through loosening the
requirements for practice. The most important alternative
approaches are economic incentives and the regulation of
postgraduate training by promoting postgraduate training
of general practitioners.25,31
Improving polyclinic performance
As major PHC providers, polyclinics are underfunded. While
having a low share of public health expenditure in GDP,
Russia spends more on inpatient care than outpatient care:
50.3% and 33.2% respectively.32 The financial priority of this
sector is relatively low. Underfunding is the major reason
for the inadequate infrastructure of primary care, the lack of
diagnostic capacity and modern IT, with the resultant long
waiting times, and rationing and underprovision of services.
There are problems with inadequate patient-flow logistics, the
appointment system, and the division of labor between physi-
cians and nurses and between individual units of polyclinics.
Contrary to expectations, polyclinics do not integrate the
coordination or continuity of care. Based on a survey of phy-
sicians in 2012,33 there was service-delivery fragmentation:
• the joint development of patient management plans by
DPs and specialists was very rare, ie, they did not work
cooperatively;
• the frequency of direct patient visits to specialists bypass-
ing DPs was high, which can be interpreted as the result
of lack of coordination of the latter;
• the frequency of timely feedback of specialists to a refer-
ring physician on the results of treatment was very low,
which indicated a low level of teamwork and continuity
of care;
• the level of awareness of polyclinic physicians of their
patients’ hospital admissions and emergency visits was
low, which limits the scope for integrative care.
The government is currently dealing with the most obvious
areas of polyclinic inefficiency. There are two major direc-
Figure 1 Number of primary-care physicians per 100,000 population between 2006–2015 in Russia.
Notes: Data from The Russian Federation Ministry of Health.39
60.0
Primary care
physicians
District
therapists
District
pediatricians
GPs
51.2 52.2 52.4 52.5 51.9 50.6 48.8 46.7 48.7 48.5
24.2
24.5
23.4
24.7
25.8
25.7
27.3
27.4
27.8
27.5
19.3 19.4 19.4 19.1 18.8 18.4 17.7 17.0 17.6 17.7
6.5
6.7
6.36.46.56.3
5.6
4.9
4.4
50.0
40.0
30.0
20.0
10.0
0.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
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Sheiman et al
tions for these activities. The first is the consolidation of
service delivery through merging polyclinics into big local
complexes. The reason for this consolidation is to concen-
trate expensive diagnostic equipment and specialists (that
are in short supply) in big facilities, thereby increasing their
accessibility. The second direction is to improve the organiza-
tion of service delivery in the polyclinics themselves.
The first strategy is particularly strong in Moscow. Since
2011, 452 polyclinics have been merged into 46 outpatient
centers for adult care, with a catchment area of 250–300,000
enrollees each. A total of 40 child-outpatient centers have
been established, with 30,000–50,000 enrollees each.34 The
enrollees of these centers now have better access to a wider
range of polyclinics, including those where major diagnos-
tic equipment is concentrated. The number of computed
tomography tests doubled from 2010 to 2014, while magnetic
resonance imaging tests tripled. The waiting time has become
much shorter (Table 1).
Access to polyclinic specialists has improved. The waiting
time for consultations reduced by 2–3 times in 2010–2014,
while their number remained constant. Improved access
can be accounted for by organizational changes rather than
additional financial input.34 Merging polyclinics in Moscow
has allowed three levels of service delivery to be developed:
DPs plus some categories of specialists – cardiologists, oph-
thalmologists, surgeons, and urologists – who are accessible
to patients without referral, most other outpatient specialists
who work in designated units of outpatient centers, and out-
patient departments of hospitals where the best specialists
are concentrated. These are linked to each other by a referral
system. The Moscow health department regulates the “routes”
of patients and establishes referral patterns according to the
availability and workload of PHC physicians. When they
are too busy, direct access to some specialists is allowed. A
new information system has been introduced to support this
organizational scheme.
Following the restructuring of the polyclinics, patients
have to travel further to reach the outpatient center where
diagnostic and specialty services are provided. However,
shorter waiting times are probably a more important indica-
tor of better access to these services. In addition to these
activities, the following innovations have been introduced:34
• Visits to patients’ homes previously made by DPs have
been shifted to a special home-visit service, which is
a separate unit. This service is staffed with physicians
and nurses who specialize in this service. There are two
objectives of this innovation: to reduce the burden on
DPs and allow them to spend more time with patients
in their offices, and to redistribute emergency calls from
the centralized city emergency service to the polyclinics,
which are closer to the patients and less costly.
• Patients can make an appointment with any DP, rather
than to a regular doctor. The objective is to encourage
patient choice and facilitate access to care.
• The position of duty physician has been introduced in
polyclinics. This physician is responsible for the provision
of care to those who need health care, but do not have an
appointment.
• Nurses’ posts have been established for concentrating
routine activities.
• IT has been introduced to facilitate appointments, medi-
cal records, prescriptions, and communication among
providers within polyclinics. Completion of this process
is planned for 2018.
• A separate unit for managing chronic multimorbidity
cases is being piloted in a few polyclinics.
These innovations have reorganized polyclinics through the
specialization of some curative and organizational functions.
The positive part of this process is the possibility to increase
physicians’ productivity and allow them to spend more time
with their patients. This is particularly important for DPs, who
are heavily overburdened.
The negative side is the risk of further decreasing the
role of DPs as core providers of PHC. With a narrowing
area of gatekeeping, they are losing their responsibility for
patient lists. Patients increasingly have to deal with physi-
cians who do not know them, which makes health care even
more fragmented. Reservations about this process were
made public by a group of Moscow district therapists. They
urged that the fundamental principle of a patient list and
gatekeeping are undermined by delegation of DP functions
to other personnel.50
The second direction of PHC reform is represented by
“Resource-saving polyclinics”. The objective is to make
PHC more patient-oriented and increase the efficiency of
Table 1 Number of diagnostic tests and waiting time in 2010 and
2014 in Moscow city outpatient centers34
Number of tests,
thousand
Average waiting
time, days
2010 2014 2010 2014
CT 278.8 570.9 60 15
MRI 59.2 197.5 50 16
Ultrasound
devices
– – 10 7
Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging.
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Semashko model of Russian Primary Care
internal processes in polyclinics. Currently, the project is
being piloted in three regions (Yaroslavl and Kaliningrad
oblasts and Sebastopol city), and is planned for the entire
country. It includes the following activities:35
• delegation of some physicians’ functions to nurses;
• improving logistics in polyclinics, including more careful
separation of patient flows across individual providers;
• improving the appointment system;
• introducing electronic communication and reducing the
amount of paperwork;
• new structural units for preventive activities.
The 2 years of this project (2015–2016) gave promising
results. According to the MoH, the average time of physi-
cians’ contact with patients doubled in these regions, appoint-
ments with physicians were easier to make, and patient
waiting time reduced by a factor of 12.35
Strengthening prevention and health
promotion
Although prevention has traditionally been an important
characteristic of primary care, a new wave of preventive
activities started in the current decade, focusing on the detec-
tion of new cases under the “dispensarization” program. The
substantial coverage of the program increased the number of
detected new cases more than sevenfold in 2015 relative to
the start of the program in 2012. Identification of the first and
second stages of cancer was 60%–80% of the total number
of new cancer cases.36
Substantial results have been achieved in the area of health
education. Polyclinics are increasingly involved in promoting
healthy lifestyles. Together with some regulatory initiatives
(decreasing smoking and alcohol abuse, encouraging healthy
diets, and building new sport grounds in residential areas),
the new policy reduced the sales of alcohol from 10.7 L per
capita in 2011 to 8.7 in 2015. The share of smokers reduced
from 35% of the adult population in 2014 to 31% in 2016.
Over the last 15 years, the share of people who are regularly
involved in physical exercise has tripled, and is now close
to 30%.37
The unsolved problem is the lack of consistency in the
implementation of the principle of dynamic dispensary sur-
veillance of detected cases. No more than half the cases with
indication of a serious disease detected under the program
are covered by constant management by primary-care provid-
ers,21 ie, follow-up activities are still limited. Moreover, these
activities are not even planned or monitored by the program.
In spite of large-scale preventive measures, a substantial
number of acute cases become chronic without appropriate
management. Chronic-disease management covers only
10.6% of myocardial infarctions, 23% of unstable cardiac
angina, and 43.6% of ischemic heart disease. The target out-
comes of these measures are not specified, and there is a lack
of teamwork among specialists.38 Therefore, the program’s
positive effect is partly devalued.
Improving primary care in rural and
remote areas
An attempt has been made to mitigate the gap between the sup-
ply of health workers in urban and rural areas. Physicians are
encouraged to work in rural areas through lump-sum compen-
sation for housing costs under the “Rural physicians” program.
The number of rural physicians increased from 44,758 in 2011
to 55,812 in 2016.35 However, these attempts have so far had
limited effect. The number of physicians willing to partici-
pate in the program decreased from 7,413 to 4,922 in 2016.
A substantial gap in physician-population ratio in urban and
rural areas still remains: 45.2 vs 14.5 per 10,000 residents.39
It is clear that the economic incentives are not strong enough
to compensate for the low basic salary of rural physicians and
lack of possibilities for professional development.
PHC in remote areas where a substantial number of
people live is also to be strengthened. The MoH has issued
a regulatory act on requirements for the location of medical
facilities with specific targets of PHC accessibility in terms of
the maximum distance between residential areas and medical
facilities. Each region of the country has developed a road
map to reach these targets in the next 3–4 years. Mobile
health units are being organized. Each residential area will
be equipped with emergency communication. The first steps
have been made to establish health telecommunication.40,41
New policy of health-worker
remuneration
Russia inherited the low Soviet remuneration of health work-
ers. Until recently, the salary of physicians was only 25%
higher than the national average (compared to two to five
times higher in Western countries).18 Nurses’ salaries are 27%
lower, and medical assistants 52% lower. The average salary
of primary care physicians is traditionally much lower than
their counterparts in hospitals. A deeply rooted perception of
physicians as a “cheap” health care resource has traditionally
limited the motivation to work in primary care.42
In 2012, a presidential decree initiated an ambitious proj-
ect to increase the average salaries of physicians to 200% of
the average wage in the economy of the region where they
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216
Sheiman et al
work by 2018, and salaries of nurses and medical assistants
to 100%. Targets were successfully reached in the first years
of this project (2012–2015), but then progress slowed, due to
the economic crisis. The original targets are most likely to be
reached in 2018, a presidential election year.
Another innovation is the “effective contract”, a Rus-
sian version of pay for performance. Health authorities and
polyclinic managers developed a set of performance indica-
tors for each category of health workers and pay them for
reaching these indicators. The major indicators for primary
care include the number of physician visits, rate of hospital
admissions and emergency calls across polyclinic catchment
areas, and number of cancer and TB cases detected at early
stages. The results of patient surveys are also taken into
account. The range of these indicators varies across regions
and individual polyclinics. According to the MoH, 83% of
employees are currently covered by an effective contract.35
The actual outcome of this policy remains unclear.
Many polyclinics use pay-for-performance schemes that
are designed to create collective incentives for better perfor-
mance, rather than incentives for individual employees. In the
first years of the program (2012–2015), additional funding
for increasing salaries was poorly linked to performance, and
thus most of the increase in average salary was not related
to the target indicators. Currently, there is a search for new
incentives.37
In contrast to Western countries, where the basic salary
makes up the bulk of remuneration, with concerns about
too much focus on pay for performance in some countries,43
in Russia the basic salary is low. For example, polyclinic
physicians in small cities often have an average basic salary
of US$200–300 per month. Bonuses added to a low basic
salary will not radically change the motivation of physicians.
A national survey of physicians in 2013 indicated that only
20% of them were ready to work more effectively with the
available bonuses and that most were seeking a higher level
of basic salary.44 This perception has been taken into account
in the recent recommendations of the MoH to increase the
share of basic salary to 85%–90% (including payment for
special conditions). Even with all these inconsistencies and
contradictions, the effective contract is viewed positively
by most health workers. This innovation, together with the
centralized policy of remuneration, may encourage better
performance by primary-care providers.
Efciency and quality of primary
care
The OECD report4 uses the following indicators of PHC
efficiency: hospital-admission rates, volumes of inpatient
care, and frequency of emergency care because of the unavail-
ability of primary care. The presumption is that stronger PHC
systems are more likely to reduce demand for inpatient and
emergency care. The major indicator of quality is patient
satisfaction with regular primary-care physicians. We use
a similar approach to evaluate the performance of primary
care in Russia.
The major long-term positive outcome is a decrease in
inpatient care. This trend is even stronger than it is interna-
tionally (Figure 2). However, the dominance of hospitals in
the Russian health care system remains. There is a strong
public perception that quality care is provided only in inpa-
tient facilities. The competence of primary-care physicians
is often questioned by patients. The capacity of polyclinics is
not always enough to take on cases that are no longer treated
in hospitals after their capacity was reduced. Therefore, in
spite of the hospital restructuring, the number of bed-days
per capita remains 70%–75% higher than in the EU and
nearly three times higher than in the US. Russia uses more
Figure 2 Number of bed days per capita in all inpatient-care facilities in Russia and selected countries in 1995–2014.
Notes: Data from Rosstat17 and World Health Organization.18
4.5
4
3.5
3
2.5
2
1.5
1
0.5
1995 2000 2005 2010 2011 2012 2013 2014
Belarus*
Russian federation*
Czech republic*
Kazakhstan*
The EU after 2004.*
The EU till 2004.*
Estonia*
USA**
0
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217
Semashko model of Russian Primary Care
inpatient care relative to most CEE countries, which had
similar indicators at the start of transition to a new model of
service delivery. Only Belarus has even higher indicators.
Both Russia and Belarus used a very conservative strategy
of primary-care development during the transition period.11,12
The number of emergency visits per 1,000 residents in
Russia was stable during 2000–2013 and then went down
sharply (Figure 3). This decrease was the result of shifting
a substantial portion of emergency visits from the general
medical emergency service (a separate institution) to poly-
clinics where special emergency units had been established.
In 2015, these units provided 279 emergency visits per
1,000 residents, in addition to 326 emergency visits made
by the general emergency service. This makes a total of 605
emergency visits per 1,000 residents. Therefore, the total
frequency of emergency visits has increased.
This indicator can be approximately compared with the
“proportion of residents who visited an emergency depart-
ment because primary care was not available” from the OECD
report for Europe as an indicator of primary-care strength.
The average of this proportion is 23% for 26 EU countries,
with most countries ranging between 8% and 30%.18 We
tentatively conclude that in Russia, the frequency of emer-
gency visits is nearly three times higher than the average for
OECD countries.
The Levada Center (one of the biggest sociological
organizations in Russia) survey indicated that in mid-2016,
44% of respondents were dissatisfied with the length of visits
to polyclinics and 63% with the qualifications and number
of polyclinic physicians.45 Similar estimates for European
countries indicate that 80%–90% of respondents are satisfied
with their GPs.2 Over the last decade, Russia has achieved
substantial improvements in health indicators – total and
specific disease mortality – and life expectancy. This is
the result of the economic growth in the early 2010s and
additional health funding; however, these indicators are still
substantially lower than in Western countries.37
Discussion
Primary care in Russia was originally well designed under
the Semashko model. Financial accessibility, a focus on
prevention, including the dynamic dispensary surveillance
method, patient lists, and gatekeeping made the system
potentially strong. However, in practice, this potential is
not fulfilled. The gap between expectations regarding the
prevailing model of service delivery and its actual imple-
mentation has increased over the last few decades. The model
does not ensure the efficiency or quality of care. There is
substantial evidence of the low priority of PHC, a shortage
of DPs, low economic incentives for medical workers, and
a gap between urban and rural areas. The detection of new
cases under a large-scale prevention program is not followed
by their management, contrary to the original design of the
system. The gatekeeping function of primary-care providers
is weakening.
The current problems of PHC have nothing to do with
the original design of the Semashko model; rather, they are
deeply rooted in the long-term developments that started in
the USSR and continued in modern Russia. First, specializa-
tion in PHC, common in many countries, has gone too far
in Russia. Specialists have replaced a substantial number
of DPs, rather than supplementing them. This process has
resulted in a decline in DPs’ clinical areas and their coordina-
tion function. They are no longer in the driver’s seat10 in big
multispecialty polyclinics. Importantly, the new division of
labor in primary care does not compensate for the shortage of
DPs, because specialists usually deal with episodic demand
and have limited commitment to the constant surveillance of
Figure 3 Emergency care visits rate per 1,000 population of Russia in 2000–2015.
Notes: Data from The Russian Federation Ministry of Health.40
380
370
360 363 365 367 369
362 362 361
365
360 361
357
343
329 326
351
359
350
340
330
320
310
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
In 2015 - 605:
general
medical
service (326)
+ emergency
units of
polyclinics
(279)
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Sheiman et al
patients’ health needs and comorbidity cases. The need for
strong generalists has not diminished.
Second, the government has lost the leverage to regulate
the supply of physicians. Postgraduate training is skewed
toward specialists, particularly those who provide private
services (eg, dentists, urologists), while the number of
generalists in training is falling. The structural imbalances
in supply have become a characteristic of the current health
system,42 which reflects the lack of strategic vision in the
governance of the system.
Third, the country has missed the shift to the GP model,
which has allowed CEE countries to extend the comprehen-
siveness of primary care.29 In Russia, the presumption was
that generalists can be strengthened by a growing number of
specialists in the model of multispecialty polyclinics. But this
has not happened. The narrow clinical area of DPs, together
with their shortage, generates demand for the growing number
of specialists and eventually leads to a shortage of specialists
as well, creating the vicious circle of shortages. The current
attempt to fill the vacancies of DPs with graduates of medical
universities without postgraduate training is a manifestation
of this process. The alternative to this approach is to train the
required number of qualified GPs with an extended clinical
area and make them major providers of primary care. This
will take a few years, but cannot be avoided.
Finally, the model of the multispecialty polyclinic as the
major provider of PHC has not changed in the transition period
and is not questioned now. Although this model is promising
for the integration of care, its potential is dependent on the
coordination of care, its continuity, and the joint work of indi-
vidual providers. There is a substantial body of international
evidence on this point.46–48 Recent attempts to consolidate
polyclinics into bigger entities is not a panacea for inefficient
service delivery. The first evidence of its impact is contradic-
tory: better access to expensive diagnostic resources is coupled
with a growing demand for specialty care and a loosening of
the coordination of primary-care providers. The same holds
true for organizational restructuring. The positive part of this
process is the possibility to increase physicians’ productivity
and the amount of time spent with their patients. The negative
side is the risk of further dismantling the role of DPs as core
providers of primary care. They are losing their patients, who
are increasingly having to deal with physicians who do not
know them well, which fragments health care even more. This
is a corollary of the excessive specialization of primary care.
The comparison of primary care models in Russia and
CEE countries29 does not demonstrate the strength of poly-
clinics relative to the smaller settings of solo- and group-GP
practices, which dominate most CEE countries. Apart from
the lack of evidence of higher integration, there is the prob-
lem of weak economic incentives in polyclinics. The recent
innovations of pay for performance are not related to the
comprehensiveness of care, and thus do not provide incen-
tives for professional development. The salary of GPs is only
10%–15% higher than that of DPs. The economic “signal”
for an entire facility does not reach individual physicians and
nurses in a big setting.49
The polyclinic model has created a new category of
specialists that provide only outpatient care and thus have
limited professional competence (eg, nonoperating urologists
in polyclinics). In the absence of GPs with a wide clinical
area, specialists work with simple cases and most specialists
are not affiliated with hospitals; therefore, their incentives
for professional development are limited. A polyclinic is an
administrative body, rather than a voluntary cooperative of
physicians in group practices. They are headed by administra-
tors who make decisions on patient lists for individual DPs,
determine the scope of preventive services, ration diagnostic
resources for each physician, and set salaries. This adminis-
trative pressure does not fit with the work of PHC providers:
the sole responsibility for the health of patients on the list,
a wide variety of activities that are not easy to predict (eg,
interaction with families, community, specialists), and the
high level of creativity that is needed to ensure the successful
management of cases. Not surprisingly, newly trained GPs
usually feel uncomfortable in polyclinics. Some of them
prefer the position of DP.
Conclusion
Russian primary care has evolved from the Semashko model
to a model that has lost some of the positive characteristics
of the original and does not ensure efficient and quality care.
This can be attributed to the excessive specialization of pri-
mary care, weak health-workforce policy, delays in the shift
to a GP model, and the dominance of the multispecialty poly-
clinic, which has not proved better than alternative models.
Some of the attempts to strengthen PHC are promising, but
they are not enough to compensate for the lack of strategic
vision in previous decades. More systematic and consistent
reforms are needed. Major lessons learnt are:
1. The low priority of primary care generates demand for
specialty care and eventually results in structural imbal-
ances in the entire health system.
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Semashko model of Russian Primary Care
2. The lack of generalists and coordination cannot be com-
pensated for by the growing number of specialists on the
staff of primary-care facilities.
3. Big multispecialty settings (polyclinics in the Russian
context) have the potential for better service-delivery
integration, but to make this happen, action is needed.
Simple decisions, like merging polyclinics, do not help
much.
4. Delegating some functions of primary-care physicians
to other categories of medical personnel may or may not
contribute to higher performance of primary-care facili-
ties, depending on how this delegation is managed.
Acknowledgment
This paper is an output of a research project implemented as
part of the Basic Research Program at the National Research
University Higher School of Economics (HSE) in Moscow,
Russia.
Disclosure
The authors report no conflicts of interest in this work.
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