The HiT reviews are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems ; describe the institutional framework, process, content and implementation of health and health care policies ; and highlight challenges and areas that require more in-depth analysis. At independence from the Soviet Union in 1991, the Russian health system inherited an extensive, centralized Semashko system, but was quick to reform health financing by adopting a mandatory health insurance (MHI) model in 1993. MHI was introduced in order to open up an earmarked stream of funding for health care in the face of severe fiscal constraints. While the health system has evolved and changed significantly since the early 1990s, the legacy of having been a highly centralized system focused on universal access to basic care remains. High energy prices on world markets have ensured greater macroeconomic stability, a budget surplus and improvements in living standards for most of the Russian population. However, despite an overall reduction in the poverty rate, there is a marked urban-rural split and rural populations have worse health and poorer access to health services than urban populations. The increase in budgetary resources available to policy-makers have led to a number of recent federal-level health programmes that have focused on the delivery of services and increasing funding for priority areas - including primary care provision in rural areas. Nevertheless, public health spending in the Russian Federation remains relatively low given the resources available. However, it is also clear that, even with the current level of financing, the performance of the health system could be improved. Provider payment mechanisms are the main obstacle to improving technical efficiency in the Russian health system, as most budget funding channelled through local government is input based. For this reason, the most recent reforms as well as legislation in the pipeline seek to ensure all health care funding is channelled through a strengthened MHI system with contracts for provider payments being made using output-based measures

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