The introduction of health insurance in the Russian Federation : an analysis of the reforms in St. Petersburg and Volgograd

This thesis examines the introduction of compulsory medical insurance in the Russian Federation in the 1990s as part of the re-structuring of welfare in the years after communism. The reforms brought in strong decentralisation of governance in comparison to Soviet rule. Minimal national legislation and guidance, subsequent adjustments in the face of implementation problems and a pattern of "negotiated federalism" have led to wide variation in regional systems within Russia. This thesis looks in particular at implementation in two federal units (from 89): Volgograd Oblast' and St. Petersburg City. In the first part, it considers the decision to introduce insurance in the context of the international health care debate, and examines the relationship between health care reform and broader issues of the "transition" away from communism to the market. Particular attention is drawn to how these two discourses in practice have run contrary to each other. It also documents experimental internal market healdi reform in die Gorbachev era in Leningrad (St. Petersburg), as well as die genesis, formulation and implementation of health insurance at the national level. The main body of die thesis considers die development of compulsory healdi insurance in die two research sites, drawing primarily on interview data from 34 interviews with representatives of die main actors widiin die new system -die municipal administration, parastatal funds and insurance companies as well as representatives of the health care workforce. Of particular significance is found to be: die impact of financial shortages on the viability of insurance; the extent to which elements of Russian local government reform can undermine regional healdi care governance; the innovation of decentralisation and the introduction of elements of contract and negotiation in place of vertical command and control structures; and conflict between parastatal health funds and insurance companies. In general die St. Petersburg system was more successful than diat in Volgograd. The former was fortunate in its local government structures and in its legacy of institutional reform in healdi care, but also key policy choices have simplified die systems operation. In Volgograd Oblast' die system suffers from over complexity, institutional conflict and a lack of clear and effective governance structures. Using testimony and analysis from Russian newspaper and journal archives these issues are explored across Russia. Regional statistical material drawn from a wide range of sources is employed to consider whatmight be the main determinants/pre-conditions (economic, political, demographic) in system design. Drawing five main conclusions in relation to the material above, the diesis additionally argues diat "marketisation", although partly the inspiration for die new system, is unhelpful as an analytical tool; that the main strength of the reforms has been to stabilise healdi care financing, but that without sufficient funds it may serve to reinforce Soviet-era distributional inefficiencies radier