The healthcare economyi General
Broadly speaking, the Russian healthcare ecosystem consists of various actors, depending on the type of activities they perform. Each type of key activity (healthcare services provision, pharmaceuticals provision, medical equipment and devices provision, etc.) is subject to a specific regulatory regime and has its own peculiarities. In this chapter we will mainly focus on a general overview of Russian healthcare law in terms of medical services provision.
The fundamental right to health protection is provided by the Constitution. Thus, according to Article 41 of the Constitution:
- everyone has the right to health protection and healthcare;
- healthcare in state and municipal health institutions for individuals must be free, at the expense of the relevant budget, insurance contributions and other funds;
- federal programmes for the protection and improvement of the population's health shall be financed by the state;
- measures shall be taken to develop state, municipal and private health services; and
- efforts that facilitate the improvement of health, development of physical culture and sport, and ecological and sanitary–epidemiological well-being shall be promoted.
One of the key pieces of legislation regulating the healthcare sector is Federal Law No. 323-FZ on the Basics of Health Protection of Citizens in the Russian Federation, dated 21 November 2011 (the Healthcare Law).
Foreign citizens living and staying in the territory of the Russian Federation have a right to medical care in accordance with the Russian legislation and relevant international treaties to which the Russian Federation is a signatory.
The Ministry of Healthcare (MoH) is the main regulatory body for the sector, responsible, for, among other things, the execution and evaluation of national health policy, regulation and oversight of healthcare services and activities developed by the private sector. The Federal Service for Surveillance in Healthcare (Roszdravnadzor) is the enforcement authority that, in particular, oversees the quality and safety of medical activity and the turnover of medicines.ii The role of health insurance
The Russian healthcare system has a highly complex nature and is based on a budget–insurance financing model.
According to Article 19 of the Healthcare Law, everybody has the right to receive (1) medical help to the extent guaranteed under the programme of state guarantees for the free-of-charge provision of medical care to citizens (the State Guarantee Programme) and (2) paid-for medical services, and other services such as those provided under a voluntary medical insurance (DMS) contract.
The principal legislation regulating compulsory medical insurance (termed 'compulsory health insurance' (OMS)) is Federal Law No. 326-FZ, dated 29 November 2010, on Compulsory Medical Insurance in the Russian Federation (the OMS Law). The OMS is a type of compulsory social insurance aimed at providing guaranteed free-of-charge medical help to insured persons. This help is paid for from OMS funds, within the limits of the particular OMS territorial programme (the Territorial OMS Programme) and, where stipulated by the OMS Law, within the limits of the basic OMS programme (the Basic OMS Programme).
The Basic OMS Programme is approved by the government and stipulates the following:
- the types of medical help available (including a list of high-tech medical help);
- a list of insured events;
- the tariff structure for medical service payments and means of payment; and
- medical help access and quality criteria.
The Basic OMS Programme guarantees the same rights to insured persons within the whole Russian territory and establishes the requirements for the Territorial OMS Programme, which must be adopted in every Russian constituency.
The Basic OMS Programme covers primary healthcare, prophylactic help, emergency medical help, specialised medical help (including high-technology help) and other areas. Territorial OMS Programmes may include types of help, and terms, in addition to those provided by the Basic OMS Programme. The extent of medical help, and tariffs, vary from region to region depending on the specific situation in the region and availability of funds.
Healthcare providers under the Territorial OMS Programme may be either public healthcare institutions or private companies (the latter should be included in the applicable register of organisations providing help under the OMS regime).
It is important to note that the structure of medical help tariffs is strictly regulated by Article 35 of the OMS Law, which sets out a list of permitted expenditures (including, in particular, salaries, purchases of medicines, costs for provision of laboratory services where a medical organisation does not have laboratory and diagnostic equipment, transport and lease costs, costs for operation of the property, and other expenditures).
It should be noted that currently the OMS tariffs do not cover any capital expenditures and, depending on the type of medical help, may differ significantly from the market prices.iii Funding and payment for specific services
In practice, most visits to doctors and basic diagnostic tests are free. Owing to mismatches between supply and demand under the public healthcare system, waiting lists for some types of services are often long (e.g., surgery or consultations for certain medical specialities). The dental package offering under the State Guarantee Programme is often limited in practice and many people opt for private dental medicine.
Certain types of beneficiaries (e.g., infants and adolescents, pregnant women, the elderly, and AIDS and HIV patients) are entitled to a number of additional rights with respect to provision of medical services on a free-of-charge basis.
Wellness services and alternative therapies are not covered by the state-run healthcare programmes and are usually funded by individuals themselves.
In some cases, citizens are entitled to pharmaceutical products free of charge (e.g., if pharmaceuticals are included in the approved list of essential medicines) or with a 50 per cent discount (e.g., retired pensioners receiving help at the ambulatory care level).
Primary / family medicine, hospitals and social care
Provision of primary healthcare to the adult population is regulated by Order No. 543n of the MoH. Primary healthcare includes measures for the prevention, diagnosis and treatment of diseases, medical rehabilitation, monitoring of pregnancy, the formation of a healthy lifestyle and the sanitary hygiene of the population. Primary healthcare is provided by medical and other institutions of the state, municipal and private systems of healthcare, and by individual entrepreneurs with a medical licence.
The Healthcare Law envisages different types of primary healthcare (pre-doctor, doctor, specialised). Primary healthcare is usually provided as outpatient care (ambulatory care) and day inpatient care.
In the context of OMS-related services, the key primary healthcare provider is a multi-speciality facility (polyclinic) combining doctors of different specialisations. Polyclinics often operate under the legal form of state-budget healthcare institutions. Polyclinics provide mostly primary (including specialised) care for non-communicable diseases, preventive and palliative care.
Primary doctor healthcare is provided by general physicians, district general physicians and general practitioners (family doctors). There are plans to further develop the institution of general practitioners and general practice medical nurses in Russia.
The social care sector is governed by a separate federal law, Law No. 442-FZ on the Fundamentals of Social Services for Citizens in the Russian Federation, dated 28 December 2013, and by other legislative acts.