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Education And Debate

Reforming the Russian health serviceOtherwise it might be convenientUrgent aid, chronic penaltiesProfessional law breakersTraining general practitioners in St PetersburgTraining general practitioners in Gatchina

BMJ 1998; 317 doi: (Published 12 September 1998) Cite this as: BMJ 1998;317:741

Reforming the Russian health service

Health service reform is an important part of the growth of democracy in Russia, and several Western groups have been helping the Russians tackle this huge task. Since 1992, general practitioners in the United Kingdom and medical teachers at the Medical Academy of Postgraduate Studies in St Petersburg have been sharing knowledge on medical education and primary health care. In this article, Dr Peter Toon, the UK coordinator, and Russian doctors involved in the partnership describe Russian health care and attempts at its reform from different perspectives.

Otherwise it might be convenient

  1. Peter D Toon (, general practitioner
  1. 137 Roding Road, London E5 0DR
  2. Medical Academy of Postgraduate Studies, St Petersburg, Russia
  3. Department of General Practice, Medical Academy of Postgraduate Studies, St Petersburg, Russia
  4. Department of General Practice, Medical Academy of Postgraduate Studies, St Petersburg, Russia
  5. aDepartment of Marine Medicine, Medical Academy of Postgraduate Studies, St Petersburg, Russia
  6. bGeneral Practice Surgery, Gatchina, Russia
  • Accepted 3 March 1998

The Russian health service is vast. Primary care takes place, not in cosy domestic surgeries, but in polyclinics that feel like small district general hospitals without inpatients. Hospitals are correspondingly massive, often with a thousand or two thousand beds. Many were built in that architecturally depressing period that gave Britain the tower blocks we are now replacing. Unfortunately, Russia has no money for new buildings and little for maintenance, so they crumble gently away.

Russian health care is burdened by its massive inhuman scale and a heavy authoritarian bureaucracy

The Russian health service is specialist led. District physicians based in polyclinics, each responsible for 2000 patients in a neat geographical patch (patient choice has yet to reach Russia) look after primary care. They do little other than treat viral illnesses, issue medical certificates, and refer about half the patients they see to specialist colleagues. Half the doctors in polyclinics are specialists, and since patients have direct access to them, district physicians are often bypassed altogether.

Obese and costly

As a Russian colleague put it, the service is “obese.” There are long hospital stays, large numbers of specialists seeing too few patients, and a heavy authoritarian bureaucracy, since every doctor's work is checked by a superior. As in the United States and France, politicians—but not the health …

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