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Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes

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Outpatient Care Delivery in the Russian Federation:

Creating a Platform for Improved Health Outcomes

WORKSHOP PROCEEDINGS

RapporteurAnna Nicholson

Planning CommitteeCris Lyn Martin

Salmaan Keshavjee

Alexandra Vacroux

Sergey Shishkin

Svetlana Sazina

National Research University, Higher School of Economics Moscow, Russian Federation

Harvard Medical School Center for Global Health Delivery-DubaiHarvard Medical School

Davis Center for Russian and Eurasian StudiesHarvard University

June 28, 2017


Contents1 Introduction 4

2 Why reform health systems? 6

2.1 The ballooning healthcare delivery crisis: from infectious diseases to diabetes 6

2.1.1 Primary healthcare as the solution to the problem of multi-morbidity 7

2.1.2 Fundamental transformation of the primary healthcare model 8

2.1.3 Lessons from Turkey 10

2.1.4 Lessons from Brazil 11

2.2 Healthcare in Russia 12

2.2.1 Emergence of a private healthcare sector 13

2.2.2 Partial transition from district physicians to general practitioners 13

2.2.3 Introduction of charges for healthcare services provided in government facilities 14

2.2.4 Trends in patient choice of healthcare providers and facilities in Russia 16

2.2.6 Priority areas for improving the quality of medical care 16

2.2.7 Key problems with outpatient care in the Russian Federation 17

2.2.8 Current government activities to strengthen outpatient care 18

2.2.9 Outcomes of outpatient care in Russia 19

2.3 “Reforming” health for improved patient outcomes: why ambulatory care systems matter 21

2.3.1 Translating scientific advances into better health outcomes 21

2.3.2 The equity argument 23

2.4 Panel 1 discussion 26

3 International experience 29

3.1 Improving outcomes with community delivery: lessons from the U.K. and Cuba 29

3.1.1 Lessons from the United Kingdom 29

3.1.2 Lessons from evolution of Cuba’s health system 30

3.2 Efforts to improve care delivery in Canada 32

3.1.3 The Canadian health system versus other high-income countries 32

3.1.4 Efforts to strengthen primary care in Canada 33

3.1.5 Features of high-performing primary-care systems 34

3.3. Delivering healthcare to communities: experience from the Netherlands 35

3.1.6 Challenges and strategies for health systems 36

3.1.7 What can strong primary care offer the health system? 36

3.1.8 Monitoring primary care with the Primary Care Evaluation Tool (PCET) 37


4 Models for improved outcomes in Russia 40

4.1 Overview of the TB situation in the Russian Federation 40

4.1.1. Russia’s national plan to detect, treat, and prevent TB 43

4.1.2 Successes in Orel, Voronezh, and Arkhangelsk regions 44

4.2 Developing a spectrum of care delivery: experience in Tomsk 46


5 Toward a healthy future 50

5.1 Imagining a reorganized Russian model of care delivery 50

5.2 Zero TB Initiative: using TB as an entry point to improved ambulatory care delivery 53

5.2.1 What is achievable? Lessons from Alaska, New York City, and Tomsk 54

5.2.2 The Zero TB Initiative 55

5.2.3 Prevention and Access to Care and Treatment (PACT) project (Boston, USA) 58

5.2.4 TB systems as an entry point for chronic care systems 59


6 References 63


IN MEMORIAMMARK G. FIELD

The workshop was presented in memory of Mark G. Field (1923–2015), an educator and scholar of medical sociology and the Soviet and post-Soviet health systems. Born in Lausanne, Switzerland in 1923, Field immigrated to the United States in 1940. Not long after transferring to Harvard in 1942, he was drafted into military service. Following the war, Field returned to complete his B.A. at Harvard, where he later received his M.A. and Ph.D. in Sociology. He began working as a medical sociologist, first in Boston-area hospitals, then as a professor at the University of Illinois at Urbana-Champaign and Boston University, where he remained until retirement. During this time, Field published a plethora of work on Soviet and post-Soviet health systems; Soviet and post-Soviet social conditions and welfare; and comparative studies of world health systems. Field was an active participant in conferences and panels and was deeply involved with the Davis Center for Russian and Eurasian Studies from its inception onward.

Source: https://daviscenter.fas.harvard.edu/news/in-memoriam-mark-g-field


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1 Introduction WORKSHOP AGENDA

Health systems in the Russian Federation and many other settings face a considerable challenge to meet the demand for high-quality healthcare. This is especially true in health systems that are skewed toward hospital-based delivery of care, especially given the high proportion of non-communicable and communicable diseases that can be successfully treated in the community. Using a bio-social lens, this workshop aimed to examine the medical, social, and economic impact of efforts to extend the reach of hospitals and clinics into the communities where patients live and work. The workshop investigated how stronger community-based and ambulatory healthcare delivery systems can complement existing hospital-based care delivery models.

The meeting was convened in Moscow at the National Research University, Higher School of Economics (HSE). On behalf of the host institution, Professor Sergey Shishkin, Director of the HSE’s Center for Health Policy, explained that the aims of the workshop were to discuss in detail the state of patient care delivery in Russia, to learn about experiences in patient care delivery in other countries, and to examine which strategies might enhance the quality and efficiency of outpatient care delivery in Russia. He thanked the workshop co-organizers and hoped that the discussions would also be of benefit to all of the international colleagues who were present. On behalf of the Davis Center for Russian and Eurasian Studies at Harvard University, Alexandra Vacroux welcomed the participants to the workshop and thanked the workshop co-organizers and staff. She dedicated the workshop to Mark G. Field and welcomed his son, Alexander, who was in attendance. Professor Salmaan Keshavjee of Harvard Medical School welcomed participants on behalf of the Harvard Medical School Center for Global Health Delivery—Dubai and Brigham and Women’s Hospital. It was fitting to hold this workshop in honor of Mark Field, he said, because of Field’s emphasis on health outcomes in the Soviet Union and the Russian Federation in the post-Soviet period and beyond. Keshavjee said that a critical

gap exists in the delivery of healthcare in the Russian Federation, the United States, and many other countries. Addressing this gap will require health systems to address the question of how to better link hospitals and clinics to care delivery in the communities where patients live and work. While hospitals are a critical node in a good health system, Keshavjee said that the aim of the workshop is to spur thinking about how to better deliver care and create systems of care delivery that are appropriate for the types of health problems we have today, especially given the increasing burden of chronic diseases worldwide. A central issue is the question of what the concept of ‘reform’ actually means in today’s health lexicon; he noted that it often refers to privatization, but the aim of the workshop is to focus on what system changes are required to improve individual and population health outcomes. Keshavjee observed that the Russian setting for the workshop is apt because the Russians have a history of thinking about how to deliver healthcare to hard-to-reach places. For example, Zemstvo medicine in 19th century Russia pioneered the idea of how to deliver care to rural communities and link people with health needs to the fruits of available medical interventions.

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The workshop was a collaborative effort by the HSE, the I.M. Sechenov First Moscow State Medical University, the Russian Society of Tuberculosis Physicians, the Davis Center for Russian and Eurasian Studies, Harvard University, the Harvard Medical School Center for Global Health Delivery—Dubai, and the Brigham and Women’s Hospital in Boston.

Funding was provided by the Brigham and Women’s Hospital, through a grant from the Eli Lilly Foundation, by the Davis Center for Russian and Eurasian Studies at Harvard University, by the Harvard Medical School Center for Global Health Delivery–Dubai, and by the HSE.


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2 Why reform health systems?

1 Smith O &Ngyuen SN. (2013). Getting Better: Improving Health System Outcomes in Europe and Central Asia. Washington, D.C.: The World Bank.2 Lee JT, Hamid F, Pati S, Atun R, Millett C. (2015). Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis. PLoS ONE 10(7): e0127199. https://doi.org/10.1371/journal.pone.0127199.

The first panel was tasked with exploring the question of why health systems need to be reformed. Rifat Atun, professor of global health systems at the T.H. Chan School of Public Health, Harvard University, spoke about the ballooning healthcare delivery crisis, which spans infectious diseases to diabetes. Sergey Shishkin, director of the Center for Health Policy at the HSE, provided an assessment of the Russian health system and its coverage of different population, examining its evolution over the last several decades. Igor M. Sheiman, professor in the department of healthcare administration and economy at the HSE, focused on the cost of inaction by providing data from Russia. A keynote address was delivered by Paul Farmer, Kolokotrones University Professor, chair of the Department of Global Health and Social Medicine at Harvard Medical School and the co-founder and chief strategist of the non-profit organization, Partners In Health (PIH). Farmer called for “reforming” health to improve patient outcomes and described why ambulatory care systems matter.

2.1 THE BALLOONING HEALTHCARE DELIVERY CRISIS: FROM INFECTIOUS DISEASES TO DIABETESIn his presentation, Atun argued that “primary healthcare offers the possibility to get more out of health systems.” He opened by outlining five categories of challenges that health systems face as they confront the ballooning global healthcare delivery crisis:

• Higher demand due to aging and a rising burden of multi-morbidity and disability;

• Low productivity, inefficiency, and poor quality of health systems;

• Widening inequalities in access to care;

• Increasing levels of citizens’ expectations about healthcare;

• Fiscal constraints that undermine efforts aimed at sustainable and equitable universal health coverage.

Atun focused first on the example of hypertension as a case study in the challenges presented by health-system failures. Worldwide, he said, hypertension is one of the most common chronic illnesses. This includes higher income countries. In Canada, which has very effective primary healthcare, 83% of people are aware of the risks of hypertension, 79% of those with hypertension are treated, and 65% of those treated had hypertension controlled. In England, those levels fall to 66%, 54%, and 28%, respectively. In the Russian Federation, levels are even lower: 59% awareness, 45% treated, and only 7% actually controlled1. Atun pointed out that this systemic failure reflects a lost opportunity to prevent morbidity and mortality.

2.1.1 Primary healthcare as the solution to the problem of multi-morbidityAtun explained that many countries around the world, including the Russian Federation, face the challenge of multi-morbidity—patients with more than one chronic illness. According to a recent study2, multi-morbidity affects 50% of people aged 66-69 years in the Russian Federation, and more than 65% of people aged 70 years and over. These rates are higher than those in other upper- and middle-income countries. The consequence is a massive burden on the health system due to increases in utilization of both outpatient and inpatient services. Patients with two chronic conditions have a 1.5 times greater chance of inpatient or outpatient service utilization than

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those with one chronic condition3. “The higher the multi-morbidity,” he observed, “the greater the utilization.” Evidence from other countries is similar. Many health systems are struggling to cope with the rising demand driven by this increase in multi-morbidity.

Atun emphasized that the solution must include access to high-quality primary healthcare. Hospitals are not an appropriate setting to treat, manage risk factors, or reduce morbidity from chronic conditions. Rather, in order to handle multi-morbidity associated with longer lifespans and aging populations, there is a need for robust systems at the community level and in primary healthcare settings. There is fairly extensive evidence to support this contention. Atun reported on a review sponsored by the World Health Organization (WHO), which looked at evidence on the functionality of health systems with a primary-care orientation compared to hospital-oriented systems. According to the review, increased availability of primary healthcare leads to higher patient satisfaction, reduces aggregate spending on healthcare, enhances equity, serves the poor better, and improves access to services. When care is shifted from specialists to primary medicine specialists, family physicians, or general practitioners, he said, there are no adverse outcomes in care quality and costs are reduced. Similarly, when service transitions from hospitals to primary care, outcomes improve and cost effectiveness increases4. Investing in primary healthcare has practical implications, Atun noted. First, it optimizes effectiveness by expanding the scope of cost-effective services that are provided in primary healthcare settings to include a core set of evidence-based interventions. Second, it optimizes operational efficiency by delivering those services through integrated care and by task-shifting from specialists to family physicians as well as from family physicians to primary healthcare teams (comprised of nurses and other health providers).

3 Lee et al. 2015.4 Papanicolas I & Smith PC, eds., Health System Performance Comparison: An Agenda for Policy, Information, and Research, Observatory Studies Series, London: McGraw Hill and Open University Press, 2013.

2.1.2 Fundamental transformation of the primary healthcare modelAtun called for a fundamental transition in primary healthcare to improve delivery of services. He explained that traditional primary care adopts a ‘doctor-centric’ model in which the first contact is with acute-demand-led services and in which continuity, coordination, and comprehensiveness of care are limited (Figure 2-1). A ‘patient-centric’ model, where most first-contact services are provided by primary care personnel for both acute and routine episodes, would be far more effective. The new model would provide comprehensive services for health promotion and prevention, expanded diagnostic capability, and community-based health services (Figure 2-2). Atun emphasized the potential impact on management of chronic disease for improving continuity of care in the primary-care setting. Continuity is essential because someone may suffer from chronic diseases, such as hypertension or diabetes, for 30-50 years. Thus, he said, primary healthcare is preferable to hospital-based care because it can achieve continuity cost effectively, with options for care across the life-cycle. Primary healthcare is also better suited to mediate the patient’s journey between community-based care and the hospital.


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Figure 2-1. Doctor-centric model of primary health care

Source: Atun, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

Figure 2-2. Optimizing functions: transforming primary healthcare

Source: Atun, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

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Atun reported on evidence that primary healthcare is equitable, cost-effective, and a potentially indispensable platform for patient-centered universal health coverage (UHC). He emphasized that primary healthcare is the best platform for addressing today’s problems as well as the problems of the future—chronic illness, multi-morbidity, and disability—that countries like Russia face.

Russia, argued Atun, has an opportunity now to revive the spirit of the 1978 Alma-Ata Declaration (1978) to address its health system challenges by introducing highly innovative primary healthcare services to tackle the growing burden of chronic disease, multi-morbidity, and disability. To illustrate the potential, he provided instructive case studies from Turkey and Brazil. He explained that both countries have introduced primary healthcare and scaled services rapidly to achieve improved health system outcomes, reduce out-of-pocket expenditures and catastrophic spending, and improve user satisfaction.

2.1.3 Lessons from Turkey Atun explained that prior to 2003, Turkey faced major health system challenges5.

Governance was highly fragmented, with five separate sources of financing for different benefits packages and very limited coverage for the poor. The country had low overall spending in health that was highly inequitable and a shortage of qualified health professionals, who were not distributed throughout the country in the areas of greatest need. In addition, there was limited use of preventative services. Hospitals often served as the first level of contact (mainly in urban areas) with long wait times, poor quality, and low levels of patient satisfaction. Lastly, there were dramatic social inequalities in health insurance coverage, in which three-quarters of Turkey’s poorest people were forced to rely solely on out-of-pocket spending on health care.

In 2003, Turkey introduced the Saglıkta Dönüsüm Programı (SDP) to address 5 Atun R, Aydın S, Chakraborty S, Sümer S, Aran M, Gürol I, Nazlıoglu S, Ozgülcü S, Aydogan U, Ayar B, Dilmen U, Akdag R. Universal health coverage in Turkey: enhancement of equity. Lancet 2013;382(9886):65-99.

inequities in health financing, service delivery, and outcomes. This comprehensive ‘health transformation program’ aimed to increase financing, expand insurance coverage for the poor, and improve access to service delivery. Atun explained that these efforts focused on developing primary healthcare competence and implementing the reforms in a flexible, strategic, and contextually appropriate way. Ongoing monitoring was used to improve user satisfaction and understand what was being valued by the end users.

Atun reported that following the introduction of the SDP, health insurance coverage for the population increased to 85% for the poor and to 96% for the richest groups; benefits were also levelled up across different insurance groups. By 2010, primary healthcare centered on family health medicine was scaled up nationwide and the entire country was covered by primary healthcare teams. Utilization of primary healthcare increased (and use of hospital services decreased) due to these scaled-up primary healthcare services, even though patients were able to access hospital services directly without any gatekeeping. Private sector utilization remained fairly flat, however. Atun noted that during the early phases of the SDP, patients chose primary healthcare for first-contact services out of necessity, but eventually they did so because they were satisfied with quality of primary healthcare providers. This shift from secondary to primary healthcare demonstrates the effectiveness of primary healthcare to provide high-quality services that satisfy patients.

The expansion of primary healthcare services also catalyzed an improvement in health outcomes, Atun reported. In 1993 and even in 2003, there were large differences in the rates of under-five mortality and infant mortality between well-educated and low-educated mothers, mothers in urban and rural areas, and mothers in the richest and poorest quintile. Following the primary healthcare reforms, however, there were sharp declines


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in both of those rates, which converged with the reduction of inequalities (Figure 2-3). Out-of-pocket expenditures at different budget thresholds also declined at 15%, 25%, and 40% budget thresholds. In 2003, the health

6 Atun et al. 20157 Hone T, Rasella D, Mauricio M, Atun R, Azeem M, Millett C. (2017). Large Reductions In Amenable Mortality Associated With Brazil’s Primary Care Expansion And Strong Health Governance. Health Affairs 36(1): 149-158.

system was the lowest rated public service (compared to social insurance, education, legal and judicial services, and public security) but by 2011, user satisfaction was extremely high and continuing to increase.

Figure 2-3. Health outcomes in Turkey: child mortality

Source: Atun and Hone et al. (2017)6.

2.1.4 Lessons from BrazilLike Russia, Atun explained, Brazil has undergone rapid demographic and epidemiological transitions with rising chronic illness and multi-morbidity. To address these potentially destabilizing trends, Brazil introduced multifaceted reforms including UHC based on primary healthcare and family medicine services. These policies were rolled out with close attention to outreach at the community and household levels. They were combined with public health interventions to manage risk factors and social determinants of health. This massive, years-long effort to strengthen primary healthcare and improve the supply of family physicians and family health teams was part of the health ministry’s

family health strategy. In 1999, there was very poor coverage throughout the country but by 2012, most of the country was covered by family health teams (Figure 2-4) and health outcomes improved as a result7.In the 1990s, Brazil had one of the worst rates of infant mortality per thousand live births in the world. However, following the scale-up of family health services there were large reductions in amenable mortality (i.e., premature mortality that can be prevented if the health system is functioning well). There were greater reductions in areas where family health strategies were introduced compared to areas where it had not been introduced as intensively.

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Figure 2-4. Brazil: primary healthcare coverage

Source: Atun and Hone et al. (2017).

2.2 HEALTHCARE IN RUSSIASergey Shishkin began his presentation by explaining the organization and key principles of the Russian health system, with a particular focus on ambulatory care delivery, offering an overview of how the system has evolved through reforms over the past 20 years. The Semashko health system, implemented in the early days of the Soviet Union, was established on the general principle of universal access to free healthcare, with free medical services provided by public health facilities. Healthcare workers received a fixed salary, but this was supplemented by informal, under-the-table payments from some patients. The system had an exceptionally high level of government involvement in both funding and provision of healthcare. Within the ambulatory care delivery model, the main providers of outpatient care were polyclinics, with a clear

distinction between pediatric and adult outpatient care. Each catchment area had a designated primary-care provider responsible for that local community. The system was oriented toward prevention through primary healthcare, with primary-care providers serving as gatekeepers within a rigid referral system for specialist and secondary-level care. This system offered patients very little choice of preferred physician or medical institution.

When Russia transitioned to a market economy in the post-Soviet era, Shishkin explained, the health system had to evolve. Public funding for healthcare fell by 40% in the 1990s and the mortality rate increased catastrophically. As the Russian economy improved between 2006-2012, he said, public funding for healthcare increased and the mortality rate declined from its catastrophic peak in 2003-2005 (16/1000


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people). Shishkin posited a relationship between mortality and public funding of the health sector, an association supported by systematic research8 Morbidity rates also stabilized during this period of economic growth. However, he noted that public funding for healthcare has once again begun to drop in the last three years due to Russia’s economic problems.

Shishkin explained that both the healthcare sector and the system of ambulatory outpatient care delivery have been restructured in recent years. Reforms to outpatient care provision include:

• Restructuring of the outpatient care facilities network;

• Emergence of a private healthcare sector;

• Partial transition from district therapists to general practitioners;

• Healthcare services provision in government facilities;

• Expansion of patients’ choice of the healthcare providers and facilities;

• Introduction of modern information systems in polyclinics (e.g., electronic medical records).

In Moscow, he explained, uchastkovy (district therapists) reforms have created a functional division of primary-care providers, with some working in polyclinics and others working in teams that make home visits. Shishkin provided data on the restructuring of the outpatient care facilities network in the post-Soviet period. Between 1990 and 2014, the number of facilities decreased from 21,500 to 17,100 and the number of physician visits per person declined only slightly, from 9.5 to 9.1 per year. In rural areas, the number of outpatient care facilities dropped from 9,200 to 3,100; rural care facilities had reduced capacity and the number of rural feldsher-midwife points also decreased (A feldsher

8 Farahani M, Subramanian SV, & Canning D. (2010). Effects of State-Level Public Spending on Health on the Mortality Probability in India. Health Economics, Nov; 19(11): 1361–1376.9 https://en.wikipedia.org/wiki/Feldsher

is a health care professional who provides various medical services limited to emergency treatment and ambulance practice9.

2.2.1 Emergence of a private healthcare sectorThe period after 1990 also saw the expansion of the private healthcare organization sector, said Shishkin. As of 2014, there were still relatively few private outpatient medical organizations (4,261), with their overall capacity representing an 8.3% share of the total capacity of outpatient facilities. However, in 1995 there were only 703 such private organizations, representing 1.0% of the total capacity. He explained that private providers work under contracts with health insurers under the mandatory health insurance scheme. In 2016, private providers represented 29% of the total number of outpatient organizations under this scheme, which is a substantial increase from 13% in 2012. However, the private providers’ share of total outpatient expenditure is only 4%, which he characterized as relatively moderate.

2.2.2 Partial transition from district physicians to general practitionersSince 2005, there has been a partial transition from district therapists (uchastkovy) to general practitioners in the primary healthcare sector, reported Shishkin. District service physicians in the primary-care sector include district therapists, district pediatricians, and general practitioners. Although the number of general practitioners is on the rise—now representing about 15% of physicians in the primary-care sector—the trend has slowed markedly with a concomitant reduction in the overall number of district physicians in the primary-care sector. The increase of general practitioners in the primary-care sector in the Russian Federation has not been commensurate with the trend in other OECD countries (Figure 2-5). For example, as of 2012, the proportions of general practitioners

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in Estonia, the Czech Republic, Germany, and the United States were between 20%-30% and in Canada and France, the proportion of general practitioners is nearly 50%. According

to Shishkin, this suggests that primary care is currently undervalued in the Russian health system.

Figure 2-5. Share of general practitioners in selected OECD countries and district doctors in Russia in the total number of physicians in 2000-2012 (%)

Source: Shishkin, based on OECD and CNIIOIZ data

.

2.2.3 Introduction of charges for healthcare services provided in government facilitiesThe post-1990 reforms have also increased the prevalence of chargeable medical services in government facilities, said Shishkin. Figure 2-6 shows trends in the percentage of patients who pay out of pocket for health services as a percentage of all individuals seeking care. For inpatient care, the percentage of patients who paid out of pocket spiked to 57% in the early 2000s, although it declined to 25% by 2015. The percentage of patients paying out of pocket for outpatient visits and for examinations and procedures has also increased, albeit more slowly. Figure 2-7

shows the increasing prevalence of informal, under-the-table payments for healthcare services. Shishkin said that around two-thirds of patients make these types of payments for inpatient care, and the rate has remained relatively stable (between 60% and 70%) since 2002, with a slight decrease between 2013-2015. For outpatient visits, examinations, and procedures, the percentage of informal payments has been steadily trending downward since 2003 as formal charges for healthcare have increased. The increase in formal, direct payments necessitates either a change in the set of guarantees or the need to increase funding for such care, said Shishkin.


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Figure 2-6. Percentage of patients purchasing healthcare services, 1994-2015*

Source: Shishkin, based on RLMS-HSE data. *Among people seeking these types of services.

Figure 2-7. Percentage of patients making under-the-table payments, 1994-2015*

Source: Shishkin, based on RLMS-HSE data. *Among patients who paid for outpatient care.

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2.2.4 Trends in patient choice of healthcare providers and facilities in RussiaShishkin reported on recent laws giving patients more autonomy to choose their preferred healthcare polyclinic. The annual open enrollment period also allows patients some latitude to choose their primary care physicians (although the procedure is more complicated). According to surveys carried out by the HSE and the Levada-Center, increasing percentages of patients are taking advantage of the new rules to make such choices. One in 10 of survey respondents had changed their regular preferred polyclinic in the previous two years (versus 5% in 2009). Almost 20% of respondents who received outpatient care had selected their facility or physician over the previous two years (versus 12% in 2009). One in five respondents who received inpatient care had selected their hospital over the previous three years (a slight increase over 2009). Shishkin characterized these trends as reflecting the success of granting patients the right to choose their provider and facility.

The surveys also revealed how patients made up their minds on the choice of a polyclinic or physician. In 2017, 51% of patients who sought ambulatory care (and made their own choice of facility/provider) attributed their decision in part to the recommendation of a physician. This represented an increase of 36% since 2009. Shishkin saw this trend as a positive development: in 2009, the largest percentage of patients (40%) had reported that they relied upon relatives, friends, or acquaintances who were not medical workers to make that decision. `In 2009 and in 2017, around half of patients who chose not to change their physician reported that the reason was satisfaction with their current physician. Citizens’ lack of trust in doctors is a key concern, according to Shishkin. A 2008 survey10 found that a greater proportion of respondents in Russia (56%) than in any other country indicated that the professional skills of most doctors were lower than required. 10 Carried out by the International Social Research Program (ISSP) in 2008.11 Survey of the adult population, commissioned by the HSE in September-October 2014, N = 4500 and in February 2017, N = 4500.

Another survey carried out in 2017 found that the percentage of respondents with this opinion in the Russian Federation has increased to 63%11.

2.2.5 Introduction of Information SystemsElectronic medical records were introduced very late in Russia compared to countries in the West, noted Shishkin, but they have not actually increased patients’ access to specialists. Many patients report that they are dissatisfied with the system because it works too slowly or is hampered by technical failures (30%).

2.2.6 Priority areas for improving the quality of medical careRespondents to HSE and the Levada-Center surveys carried out in 2013 and 2017 were asked about their priority areas for improving the quality of medical care. In both years, the most common response was a “more conscientious attitude of medical personnel to their duties” (50% in 2013 and 45% in 2017). Other common responses are presented in Figure 2-8. Shishkin concluded by reporting that the population’s agenda for reform includes better territorial availability of health services, better access to free services, and improved trust and confidence in healthcare providers and their providers’ skill levels.


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Figure 2-8. Priority areas for improving the quality of medical care in the Russian Federa-tion

Source: Shishkin, based on data from the HSE and Levada-Center surveys. The Cost of Inaction: Data from Russia12

12 Distribution of respondents’ answers to the question: “In what areas is it necessary, first of all, to improve the quality of medical care?”

Igor Sheiman summarized two major “cost of inaction” studies carried out by HSE. One study focused on the issues and outcomes of outpatient care in Russia compared with other countries, and the other was a large-scale study that compared primary care in the Russian Federation to that in Eastern European countries along 40 different indicators.

2.2.7 Key problems with outpatient care in the Russian FederationSheiman focused on several key problems of outpatient care in Russia: underfunding, excessive specialization of primary healthcare, the shortage of district service physicians, and inadequate qualification and competencies of district service physicians. Two other major problems, which are critical but were not the focus of his talk, are underfunding and low levels of service integration, both within polyclinics and between polyclinics and hospitals.

Turning to the problem of excessive specialization of primary healthcare, Sheiman noted that this is an issue which emerged in the 1970s when many of the services that uchastkovy (district therapists) used to provide were transitioned to specialists, which undermined the traditional system of referrals. Today, specialists make up 65%-70% of the overall number of polyclinic physicians in Russia, while district physicians make up only 11% of all physicians in the country. Sheiman pointed out that this is a substantially lower percentage than in OECD countries. For example, in France the proportion is 45%. Specific types of outpatient specialists are no longer involved in provision of inpatient care. As a result, district therapists and pediatricians now provide a limited range of services that are only needed by a small number of patients. This comes at the expense of their former organizational and coordinating functions, since they no longer serve as gatekeepers or coordinators

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for their patients’ care13. Sheiman pointed to an ongoing debate about how primary care should be structured, citing Boerma’s concept of “extended” primary care14, i.e., the involvement of multiple specialists and subspecialists, including nurses. The key question, he said, is whether or not this type of composition actually strengthens primary care. He argued that Russia has an extreme version of extended primary care in which primary care and outpatient care are practically one and the same.

Regarding the second problem—the acute shortage of district service physicians—Sheiman estimated that there is a 33% shortfall in district therapists (terapevts) and a 10% deficit in district pediatricians. Each district therapist is responsible for an average of 2600 residents (3000-3500 residents in some regions), which far exceeds the target of 1700 set by the Ministry of Health. General practitioners make up only 13% of the total number of district physicians, compared to the norm in other Central and Eastern European countries, where general practitioners make up more than 90% of physicians. According to Sheiman, the primary reason for this shortage is that the government has forfeited control over the makeup of the health workforce. Only 20% of medical schools even offer general practice as a subject in postgraduate education (in most European medical schools general practice is a standard part of the curriculum). Only 3% of Russian medical school graduates have any postgraduate education in general practice. There is very little motivation for physicians to enter primary healthcare, Sheiman said. He noted that none of the federal health strategies in Russia over the last few decades have explicitly resolved to support district health services, let alone adopting a general practitioner model.

In addition to overspecialization, Sheiman said, district service physicians also suffer

13 Denisov I. (2007). Family Medicine Development in Russia/Glav Vrach, No. 5. In Russian.14 Kringos DS, Boerma WGW, Hutchinson A, & Saltman RB. (2015). Building Primary Care in a Changing Europe. Observatory Studies No. 38, Copenhagen: WHO, for European Observatory On Health Systems and Policies. 15 Sheiman I & Shevski V. (2017). Two Models of Primary Health Care Development: Russia vs. Central and Eastern European Countries. HSE Working Papers, No. 6, National Research University (Russia).16 Kringos et al. 2015.

from deficits of training and professional competence. The mandatory curriculum for these physicians is less rigorous than the standard medical school course of study, and continuing medical education requirements only require district service physicians to renew their qualifications every five years, meaning that practitioners’ technical understanding is often outdated. An HSE survey15 based on European Primary Care Monitor methodology estimated (optimistically) that only 70% of primary-care visits are handled by district physicians on their own, without referrals, compared to the European rate of 85%-95%16. Of nine diseases that are commonly treated by general practitioners in Central and Eastern European countries, only five are routinely treated by district physicians in Russia.

2.2.8 Current government activities to strengthen outpatient careSheiman took note of recent government initiatives to strengthen outpatient care, which include attention to strengthening the outpatient care infrastructure, IT development, general practice development, providing new methods of payment, and setting new policies for remunerating health workers. He focused in on three of those elements in particular: service restructuring, organizational changes in polyclinics, and health professional development policy.

For example, the 450 adult polyclinics in the region of Moscow were recently consolidated into 46 outpatient centers with catchment areas of 250-300 thousand residents each. The major objective of the reorganization is to consolidate the ‘rare’ resources—such as expensive diagnostic devices and specialties—to make them more accessible. As a result of merging the polyclinics, important diagnostic tests are much more accessible, there are shorter waiting time for visits to some


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specialists, and administrative costs are lower. However, patients have longer travel times. Another problem, Sheiman said, is that many specialists are forced to function as primary care physicians, because “if the uchastkovy know very little, then you have to send the specialists down to provide effective care.” District physicians are often overburdened and have limited qualifications; further, there are insufficient links between tertiary-level care services (hospital specialists) and primary/secondary-level care—“you can go directly to them,” he said, “bypassing the gatekeeper.”

Other regions, noted Sheiman, have used different strategies for service restructuring. For example, the objective of strengthening multi-level service delivery has led to the establishment of interregional specialty centers to serve residents of multiple adjoining areas. The hope is that concentrating specialty outpatient care will improve access to specialty care for the rural population. However, the outcome of this long-term project remains unclear. The Moscow model for organizational changes in polyclinics has created special units responsible for home visits to help lessen the burden on district physicians, for example by utilizing nurse posts for routine services. Information technology is employed for medical records, scheduling, prescriptions, and physician communication. Patients can choose to visit the district physician of their choice and patients with chronic conditions are referred to specialists for care. In the last decade, per capita inpatient services in Moscow have declined. Sheiman warned however that while specialization may improve physician productivity, the Moscow model could undermine the concept the doctor/patient relationship in the long run. Moreover, it may require more specialists to function properly, while underutilizing nurses.

Sheiman described a new development policy for health professionals that emphasizes preventative care. The policy sets new educational standards, extends the length of medical school, and mandates more frequent

continuing medical education requirements, which can now be fulfilled at more institutions. As of 2017, physicians will be accredited at multiple levels; medical school graduates will receive a preliminary accreditation to work as a district therapist or district pediatrician.

2.2.9 Outcomes of outpatient care in RussiaSheiman described the large-scale program of dispenserization (dispenzerisatsii) that has a special focus on prevention. According to the government data, this initiative increased detection of diseases such as cancer by more than seven-fold by 2014. The initiative’s health education programs have also yielded some positive outcomes. However, he noted, it fails to adhere to the principle of dynamic surveillance: there is a lack of follow-up care once cases are detected and only a very limited number of programs for helping patients manage chronic conditions. District physicians are overburdened, and experts have questioned the cost effectiveness of some types of screenings. Total morbidity has been increasing faster than primary morbidity, he noted, which indicates the “chronicization” of some detected cases.

Sheiman discussed additional indicators of outpatient care outcomes, such as the hospital admissions rate and the inpatient care volume. As of 2014 the Russian Federation still had substantially more inpatient days per capita than the United States or European countries, but he said that the volume is decreasing. Compared to other countries in the former Soviet Union, he reported, Russia has a very high number of total hospital admissions (21.8 per 1000 residents) and inpatient bed days per resident (2.61) exceeded only by Belarus (33.1 admissions per 1,000 residents and 3.34 bed days per resident). Sheiman noted that both of those countries have undergone a significant systemic reform in their primary care systems.

Another indicator that improves outpatient care and has a positive impact on the health

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system as a whole is the rate of emergency care utilization. According to 2016 data from the OECD, the proportion of residents who visited an emergency department because primary care was not available across Europe was 23% (with a variance of 8-30% across countries). In the Russian Federation, the

17 Kringos et al. 2015.

proportion is 60% (Figure 2-9). Thus, Sheiman concluded, inpatient and emergency care utilization are substantially higher in Russia than in Europe, an indication of weakness in the outpatient care system, and particularly in primary care.

Figure 2-9. Emergency care visits rate per 1000 population in Russia, 2000-2015

Source: Sheiman, based on 2016 HSE data.

The final indicator Sheiman discussed was the level of patient satisfaction. According to a 2016 Levada Center survey, 44% of respondents were dissatisfied by the inadequate length of the interaction with their healthcare provider. Meanwhile, 63% felt that polyclinic physicians did not have adequate training. Sheiman noted that the level of patient satisfaction with district physicians was even lower. According to a 2010 Roszdravnadzor survey, only 14% of respondents were happy with their district physicians. In contrast, between 80% and 90% of those surveyed in other European countries were happy with their general practitioners17.

In conclusion, Sheiman argued that outpatient/ambulatory care in Russia was initially well conceived, with its emphasis on preventative care, as well as its multi-level

delivery of care with district physicians as gatekeepers. The polyclinics, he suggested, have started to work and collaborate more effectively. However, there is still much work to be done to meet standards for teamwork, coordination, and continuity of care within polyclinics. Furthermore, follow up is not always adequate. The most important concern, he said, is that specialists are not supplementing district physicians, but rather replacing and marginalizing them. This undermines the referral system and has led to an acute personnel shortage at the primary care level, with district physicians unable to serve in their mandated role as gatekeepers to coordinate and take responsibility for the care of individual patients, a key principle of the Semashko model. “The system is being diluted,” Sheiman warned.


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2.3 “REFORMING” HEALTH FOR IMPROVED PATIENT OUTCOMES: WHY AMBULATORY CARE SYSTEMS MATTERAt the outset of his keynote address, Paul Farmer remarked on a claim he often encounters that the lessons learned in places like Rwanda about health systems, social determinants, access to care, financing, and so on could not possibly be relevant to settings with more access to “staff, stuff, space, and systems.” In fact, he argued, the experience of countries like Rwanda in delivering community-based care close to where people actually live (not in polyclinics or hospitals) is deeply relevant for treating acute illnesses and, especially, for treating chronic diseases. Farmer termed this type of inquiry the ‘science of delivery.’ He advocated for community-based care not because he is a specialist in the discipline, but because community-based care is a prerequisite for making the difference in settings with large burdens of chronic disease and acute illness. Farmer warned that people sometimes conflate their own areas of expertise with the systems-level interventions that are needed to improve health outcomes.

2.3.1 Translating scientific advances into better health outcomesFarmer highlighted “three Ds” that are key to translating scientific advances into improved health outcomes: discovery, development, and delivery. In Russia and elsewhere, determining what balance of these health system elements is needed requires careful consideration. Each of the three components requires staff, stuff, space, and systems to fulfil its particular function. People working in discovery, development, and delivery have different responsibilities for achieving the broader aim of better health outcomes. For example, he cautioned against hijacking gifted basic scientists to carry out administrative or clinical duties.

18 Favour CB, Janeway CA, Gibson JG, & Levine SA. (1946). Progress in treatment of subacute bacterial endocarditis. NEJM 17;234:71-77.

Discovery science, said Farmer, conducted mostly in laboratories, is still the foundation of public health and other branches of biomedicine today, as has been the case since at least the latter half of the 20th century. But ultimately, he noted, these interventions must be delivered to patients when and where they need them. A person with kidney failure needs a health system that can provide dialysis or a kidney transplant. A person hit by a car needs good trauma care nearby. But in some situations, the person may be blamed for not looking both ways before crossing the street, or the malaria patient may be blamed for not using a bed net. These examples demonstrate the inherent risk of looking at the social determinants of illness without thinking about equitable care at the other end, he said.

A key challenge worldwide, Farmer argued, is the integration of preventative interventions informed by an awareness of social determinants of health with a commitment to equitable care based on rigorous scientific research. This feat of integration is a particular challenge for countries like Russia and the United States, which have the capacity to translate scientific discoveries into meaningful improvements for patients. To show how radically the picture can change in the wake of discovery and development, Farmer compared the mortality rates for subacute bacterial endocarditis among patients treated at Peter Bent Brigham Hospital in Boston, MA, during the pre-sulfonamide era (1913-1937), the sulfonamide era (1937-1944), and the penicillin era (1944-1945)18. Prior to the development of sulfa drugs, virtually all these patients died of the infection. By 1945, mortality rates for these patients dropped by more than half as the direct result of a technological advance—penicillin—that came from basic science and was then developed primarily by for-profit pharmaceutical companies.

Farmer argued that delivery is the least well studied of the three Ds: “There is no delivery science,” he said, “until we build it.” To illustrate, he showed the dramatic reduction in rates of mortality after acute myocardial

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infarction between 1970-2005. Researchers were hard-pressed to pinpoint the cause of this trend among the complex of potential factors, such as beta-blockers, statins, lifestyle changes, and so on. It was almost two decades before doctors began routinely acting on the discovery that beta-blockers after acute myocardial infarction significantly reduce mortality (Figure 2-10). Quinine was isolated from the bark of a Peruvian tree species (cinchona bark) by French researchers in 1820, many decades before it was regularly prescribed by practitioners in areas where malaria was a leading cause of death. This was despite the fact that it almost completely

19 Tom Lee, “Care Redesign,” Lecture for Introduction to Social Medicine, Harvard Medical School (28 Oct, 2010).

prevented malaria mortality. Delivery failures are common, said Farmer, but they “are not the fault of basic scientists…it is not the fault of the people who discover that the bark of a tree could be formulated into something that could reliably treat malaria.” Similarly, it was once believed that breaching the body’s surface (e.g., by cannulating the bloodstream or putting in a catheter) would inevitably lead to infection in at least some patients, said Farmer. This was proven wrong by studies of delivery and delivery failures showing that infections could be significantly reduced (Figure 2-10).

Figure 2-10. Heart attack death rate, 1970-2005; Bloodstream infections per 1,000 device days for 6-month periods

Source: Farmer, based on Lee 2010, graph data from HPM Close quarterly reports19.

The community-based delivery platform is easy to describe, said Farmer. Community-based care should be delivered in a patient’s home, workplace, or wherever the patient may be. In Tomsk, for example, sometimes it means meeting a patient in a bar, or near a liquor store, or in a train station. The platform should be community-based,

health-center-enriched, and hospital-linked. In his experience, most care can be delivered in clinics by nurses, but people with leukemia, Ebola, or acute trauma need a network with hospitals that have tertiary-care capacity. While this is not a matter of dispute in Russia, many development specialists—who undoubtedly have access to tertiary care


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themselves—claim that hospitals are “black holes” for resources in developing countries, remarked Farmer. But that argument ignores the obvious fact that they are an indispensable part of the health system. PIH built a hospital for Rwandan Ministry of Health in a district of 350,000 people with no doctor and no hospital: “Why would you want to moderate the use of clinical services in a place that desperately needs them?” he asked.

In some areas, Farmer cautioned, the word ‘reform’ is code for privatization. “It is,” he said, “a way of not speaking honestly about the intent to privatize public services.” This is very much the case in the United States, he noted, as well as in Russia.

In many discussions, code words are used with varied intentions. Across Africa, for example, the word ‘reform’ is synonymous with the reduction of public expenditures for healthcare delivery. In reality, the so-called coupons (or ‘moderating tickets,’ as translated from French) that are employed in health system reforms across Africa are actually aimed at moderating the utilization of healthcare services. Japanese people visit a health professional an average of 14 times per year, reported Farmer; in Malawi and Rwanda, the average number of visits is less than 0.5 per year. “Why,” asked Farmer, “would we want to moderate that with a fee or some other type

of mechanism of health system reform that so far has not served anyone?” He argued that the word ‘reform’ has become semantically hollow and is no longer useful.

2.3.2 The equity argumentFarmer defined the ‘equity argument’ in social justice terms: every time there is a new medical advance—be it medication, diagnosis, or preventative techniques—there is an equity challenge in distributing it (Figure 2-11). Hepatitis C therapy is today’s critical equity challenge, he said. The infection can now be completely cured, but in the United States, the treatment is outlandishly expensive because it is perceived that the market can bear such expense. Farmer asked: “What is the equity plan for these types of new therapies that stem from basic science and are developed by the biopharmaceutical industries?” He argued that the equity plan needs to involve publicly financed health delivery systems that are easily accessible to people wherever they live. He was not surprised that most complaints about healthcare in Russia come from people in Moscow, which is the richest area and has the most services. Poor and disenfranchised people are also complaining, he noted, but they are not being heard.

Figure 2-11. The equity argument

Source: Farmer, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

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Farmer reflected on the early 1990s, when AIDS was the leading killer of young adults in the United States and the hospitals were full of people dying of the disease. AIDS mortality in the Western world plummeted when antiretroviral therapy (ART) for AIDS was introduced in 1996. Even in U.S. healthcare settings, rates plunged, although access remained inequitable at a systemic level. But despite triumphalist rhetoric like the Newsweek headline, “The End of AIDS,” treatment costs amounted to $15,000 per person per year, and the very same popular magazine acknowledged that some HIV-positive people were being excluded as “too poor to treat20”. A few U.S. states created lotteries to distribute AIDS treatment to poor people, he noted, but other states did not even bother to treat their poor patients. A lottery is not a model for a sound health insurance system based on need, Farmer said.

In the United States, Farmer noted, the issue of the uninsured remains a matter of significant debate. Up to 18% of the GDP is currently being spent on delivery21 for results that do not compare favorably with results in European countries. “We put in more money and we get less in the way of results,” Farmer said. U.S. hospitals that receive federal funds must admit uninsured people to their emergency rooms. Some hospitals circumvent this by calling their emergency rooms “observation decks,” because they do not want trained emergency physicians providing primary care. However, Farmer cautioned, “it is very expensive to provide low-quality medical care to poor people in a rich country.”

By contrast, said Farmer, poor people in a poor country can just be ignored, as was done for a decade for people with AIDS and drug-resistant TB. In Africa, AIDS was also the leading killer of young adults as well as children. But despite the advent of ART, AIDS mortality rates in Africa continued to rise

20 Pederson D, Larson E. (1997). Too Poor to Treat: States are Balking at Paying for Pricey AIDrugs. Newsweek July 28; 130(4):60. 21 U.S. Centers for Medicare and Medicaid Service (CMS). NHE Fact Sheet. Available at https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/nationalhealthexpenddata/nhe-fact-sheet.html. 22 Rich ML, Miller AC, Niyigena P, et al. (2012). Excellent clinical outcomes and high retention in care among adults in a community-based HIV treatment program in rural Rwanda. J Acquir Immune Defic Syndr. Mar 1;59(3):e35-42.

catastrophically after 1996 because there was no plan for delivery. In the U.S., he explained, basic science and research were largely publicly funded, and development was driven by biopharmaceutical concerns. Delivery was carried out, albeit haphazardly and often through public insurance.

Farmer described John, a patient in Rwanda with comorbid AIDS, disseminated smear-positive TB, and malnutrition. Doctors in Rwanda thought that John had no chance of survival, but he was treated successfully in a PIH community-based delivery platform program. This was made possible by the discovery of ART through basic science and the development of the therapy by pharmaceutical companies. Patient stories like these are relevant, he said, because health policy is formulated by anecdote. Academics can disseminate masses of data that ambulatory, community-based care is not only more effective but also less expensive. However, the data itself will not necessarily drive reform. It is often people who know someone who has been treated successfully that makes the difference, Farmer remarked.

In Rwanda, the first 1000 patients with AIDS who enrolled in community-based care—delivered by a community-based health worker at home, with clinic/hospital visits only as needed—had a default rate of under 3% after two years22.

Farmer argued that this would not be achievable in the U.S., even within a clinical trial, because there are no community-health workers and patients must visit clinics or hospitals for utterly routine checkups. In Rwanda, community-based care was scaled up nationwide under the auspices of a “health system strengthening” campaign. After the genocide left Rwanda the poorest country in the world, the Rwandan government invested approximately 20% of their public budget into healthcare and delivery. In comparison,


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Liberia and Sierra Leone23 both invest less than 3% of their public budgets, which is why they lack the staff, stuff, space, and systems to stop Ebola, according to Farmer. Because of Rwanda’s heavy investment, child mortality rates in the country declined by 2010 to some of the lowest levels in Sub-Saharan Africa. In terms of universal access (per WHO criteria) to AIDS treatment, Rwanda exceeds both the U.S. and Russia. Rwanda was the first country in Africa to achieve the 2015 Millennium Development Goal target of 80% ART coverage (Figure 2-12), Farmer reported, and

23 Farmer noted that because of its extractive trades (diamonds, bauxite, minerals, etc.), Sierra Leone had one of the highest GDP rates per capita in the world the year the Ebola outbreak began, but among the poorest people. He construed this as neoliberalism—“a lower school of economics”—in action.24 Farmer PE, Nutt, CT, Wagner CM, et al. (2013). Reduced premature mortality in Rwanda: lessons from success. BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f65.

they did so at low cost and in a country with low GDP per capita. The successful outcomes in Rwanda are not due to the involvement of more infectious disease specialists, said Farmer, who warned against “confusing your own professional training with what is needed to make a difference for the majority.” The outcomes were achieved by community-health services, nurse-directed clinics, and a public system that created a safety net which did not exist in Rwanda before and still does not exist in most countries of the region today.

Figure 2-12. The Results: child mortality in Rwanda, 1990-2001

0

50

100

150

200

250

300

1990 1995 2000 2005 2010 2015 MDG

Target

Pr obabilityofchilddyingbyage

5per 1,000livebir ths

Figur e2. Child mortality in Rwanda, 1990 – 2011

Rwanda

Sub-SaharanAfrica

World

Farmer, et. al. BMJ 2013;346:f65

T he R esults

Source: Farmer, based on data from Farmer et al 201324.

Global survey data reveal steep declines in avertable mortality among young people in Rwanda over the last 15 years. In fact, Farmer maintained, these declines are more dramatic than any registered anywhere else in the world at any time in human history. The question of how these rates compare with other rapid declines in history is an important one, he argued. There is pervasive confusion about social determinants versus care delivery systems, which are often in

competition. People need care when they are sick, he explained, but the impact of social determinants varies according to the setting and the burden of disease. Figure 2-13 depicts Rwanda’s steep decline compared to other famous historical declines in mortality. Farmer described Rwanda’s success as driven by a publicly funded, well-distributed care delivery system that relies very heavily on community-health workers to complement emergency and specialist care systems.

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Figure 2-13. Probability of death before 5 years of age (per 1,000 live births)T he R esults

Source: Farmer, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

Farmer concluded by proposing that, in order to tackle the burden of chronic disease, we must create durable links between universities, hospitals, and patients’ homes and workplaces. These connections can sustain an effective care delivery system which reaches everyone. The enterprise needs staff, stuff, space, and systems. “It’s not rocket science,” he observed, but it does require money: even the best-conceived policy or program is toothless without financing. He contended that the focus should be placed squarely upon finding ways to move financing to more sensible systems, rather than being diverted into taxonomic squabbles about prevention versus curative care, social determinants versus tertiary care, tuberculosis versus malaria, and so on.

2.4 PANEL 1 DISCUSSIONYuri Komarov suggested creating specific departments to train primary-care providers, because it is a specialization in its own right that requires a specific type of training. He

also argued that mass-scale health services should be universally accessible and delivered as close to the community as possible, with nurses serving as the backbone to carry out home visits and physicians involved only if necessary. Regarding Sheiman’s presentation, he noted that the Semashko system has another important principle that was not mentioned: the mass involvement of citizens in community-based healthcare. The Semashko model has been mentioned as a return to Soviet times, he said, because they were commendable patient-centered principles. The good elements should have been preserved and the bad elements discarded, rather than the other way around. He emphasized that only preventable mortality depends upon healthcare—not all mortality. He explained that the Russian constitution construes health protection and healthcare provision differently: the former is a high-level responsibility of government leadership (although they do not know this) while the latter is a health-sector responsibility. Komarov argued that the Ministry of Health should not be


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responsible for all healthcare, but for restorable health. Healthcare should be more of a ‘repair station,’ where people come to be restored and repaired, and the government should be responsible for motivating people and promoting healthy lifestyles, but it does not.

Komarov noted that Atun’s presentation did not touch on a critical point: the key word is ‘care.’ Primary care about health is not just another doctor receiving patients; it is a doctor taking care of people’s health. This nuance must be inculcated as part of all training of health personnel, he contended. Conversely, delivery science must not focus only on clinical work and visits, he suggested. There should be a focus on creating health improvements rather than healthcare systems. Health system development and health promotion systems are different things, he argued. Primary-care providers know what is going on in their communities and they can provide a link with local authorities in a way that no one else can. Komarov also noted that general practitioners are syndromic, not nosological doctors. Their goal is not to diagnose but to provide solutions. He suggested investigating whether individual or group practice is better for caregiving, and in which cases one is preferred to the other. Regarding emergency care, he said that it was becoming less and less effective in Russia and the number of visits is decreasing for logistical reasons: subnational authorities, rather than municipal authorities, are responsible for emergency care. Travel times have increased, the radius of service provision has increased, and ambulances are restricted to a 20-minute limit. Costs have increased dramatically in just one year. Komarov argued that this money should be turned over to municipal authorities instead, where it would be better spent.

Another participant agreed with Komarov that public health systems in Russia are lacking compared to other countries, which must be examined over the next five years. She noted that when utilization and volume of inpatient care decrease, it reduces administrative capacity, reduces the number of hospital beds, reduces the volume of government guarantees of paid inpatient care, and thus reduces the

throughput capacity. She wondered: “Is this a panacea?” Given that increasing the number of trained general practitioners will take more than a decade, she suggested that compensation for those practitioners will need to increase commensurably if they are asked to take the extra time needed to visit with each patient per this approach. She estimated that this would cost an additional 90 billion RUR. The existing funding cannot be reallocated, she warned, so funding will need to be increased from outside of the health system. If healthcare funding had not been drastically reduced in the 1990s, which underfunded the polyclinics and uchastkovy (district physicians), she suggested, and the system had been strengthened instead, then perhaps this problem would not exist today. Instead of artificially killing the Soviet system, perhaps it should have been gradually reformed and modernized, in terms of skills level and remuneration as well as structural reforms.

Patrick Pietroni cautioned that a systems approach to reform is essential, because there are so many different levels that need to be reformed. He suggested that primary healthcare may need to “grow up and grow out of its link with medicine” and into a community-oriented primary care where health is involved, because the social determinants of health are far more important than some of the biological elements. He also noted that reforming health systems will require reforming medical education so that healthcare providers will be able to navigate the new system and focus on primary care rather than medicine.

Boerma asked whether the Russian health system is actually a system at all, because a system—by definition—should be coherent in its response to the health needs of the population. He asked why the number of providers is being scaled up in Moscow—“is there a vision for primary care and ambulatory care, and who is in the lead? We have an orchestra without a director.” He warned that different groups often have diverse priorities, which may conflict with each other. He called for more workforce planning, as opposed to simply more doctors. He agreed

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that reforming the medical education system is necessary, but suggested first asking: “What kinds of doctors do we need, for what kind of system, to solve which types of problems?” Broadly, he suggested starting these discussions from an overall-system perspective.

A representative from the Russian Ministry of Health explained that they are aware of these problems, and commented on the specific issue of rural healthcare provision. To speak only about paramedics and midwife centers is too limited, she said, because there have been

some changes: in fact, there are 157 urban settlements where the number of primary care facilities is increasing. Meanwhile, the number of outpatient centers and general practitioners in rural areas is also increasing. She warned that the population will need to be educated and prepared for this transition to a new system of primary care, referring to multiple complaints from Moscow residents which suggest theirresistance to change.


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3 International experienceThe second panel featured three speakers with presentations focusing on international experiences in care delivery. Patrick C. Pietroni, emeritus dean of general practice at London University and director of Darwin International Institute for the Study of Compassion, spoke about improving outcomes through community delivery, with a focus on lessons gleaned from work in the United Kingdom and in Cuba. Efforts to strengthen primary-care delivery in Canada were discussed by Brian Hutchison, professor emeritus in the departments of family medicine and health research methods, evidence, and impact and the Centre for Health Economics and Policy Analysis at McMaster University. In his presentation, Weinke Boerma, senior researcher at the Netherlands Institute of Health Services and Research (NIVEL), described experiences in delivering healthcare to communities in the Netherlands.

3.1 IMPROVING OUTCOMES WITH COMMUNITY DELIVERY: LESSONS FROM THE U.K. AND CUBAPatrick Pietroni said that care, concern, compassion, communication, and courage are the key elements that will drive the type of health system that many have been struggling to create. He cautioned that epidemiologists and public health specialists tend to speak in statistics, but “statistics can stop you from thinking and more importantly, they can stop you from feeling.” Pietroni highlighted the importance of recognizing that people present with problems that may be emotional and/or social as well as physical, and thus cannot be placed easily into a diagnostic category. He called for loosening the link with the medical world and focusing on community-oriented primary care, which requires looking at the entire system. Health is included, but it is only one part: “it is no measure of health to be well-adjusted to a profoundly sick society.”

3.1.1 Lessons from the United KingdomAs an anecdotal example from the United Kingdom, Pietroni described the case of an older Bangladeshi man who came in complaining about his stiff, sore knees. There was evidence of some arthritis, but the pain persisted despite treatment. When asked if he had difficulty praying while on his knees, per Muslim custom, the man responded that he did; since his wife had recently died, he prayed five times a day to feel closer to her. The doctor reached out to the man’s imam, who proposed a dispensation that would allow the man to pray without kneeling. Medicine should be bio-social-spiritual, said Pietroni. For many people, the spiritual side of their life is critical for enabling them to sustain the challenges they face. A community-oriented primary-care system should facilitate and encourage that, he said. The provision of community-oriented primary care should employ community assets in addition to healthcare professionals. To illustrate, he described an analysis at his practice that found two main groups of patients whose number of annual visits to healthcare providers tended to be greater than others: elderly, isolated patients and teenage mothers. A community-health worker noted that both of those groups tend to live in the same high-rise residential buildings. They convened the two groups for tea to introduce them to each other and, after a few meetings, the groups began socializing together of their own volition and formed important social bonds.

Pietroni outlined a set of factors that determine health systems:

• Cultural and population needs;

• Ideological and political factors;

• Funding and finance factors;

• Managerial and organizational factors;

• Professional and clinical factors;

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• Educational and research factors;

• Top-down versus bottom-up leadership;

• Change management.

He compared the relationship between primary and secondary care systems in several countries (Figure 3-1). In the U.K., for example, 90% of patient contact is with the family doctors in the primary health system

and 10% of contact is secondary care in the hospital. In the U.S., 60% of patient contact is with specialists, 30% with hospitals, and only 10% with family doctors. In the Russian Federation, 100% of patient contact takes place in primary-care polyclinics. Similarly, in Cuba, almost all patient contact (95%) takes place in primary care (polyclinics and family doctors).

Figure 3-1. Comparison of relationship between primary and secondary care systems

Source: Pietroni, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

3.1.2 Lessons from evolution of Cuba’s health systemPietroni traced the evolution of the health system in Cuba. In the pre-Castro period prior to 1959, the infant mortality rate was 60/1,000, the rate of maternal mortality was 125/100,000, and the average life expectancy was around 60 years. Many doctors fled the country after 1959, leaving only about 6,000 in the country. During the Revolutionary period (1959-1963), the state assumed full responsibility for the health of the people, with the health system guaranteeing UHC for all and preventative care as the primary goal.

People’s active participation in maintaining their own health was a core tenet of the systemic reform, Pietroni explained. Between 1963 and 1982, the system was modeled after the Russian hospital and polyclinic program, with primary care as a specialty. By 1980, the number of doctors per capita had risen to 25/10,000 from 8/10,000 in 1959. During the 1980s, Castro sent a team around the world to look at various types of health systems and concluded that the British NHS system was the best model, except for the conceptual and institutional distinction between primary care and public health, which were integrated in Cuba. This era saw the emergence of


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the family doctor service and fundamental changes to medical education, said Pietroni. By requiring all medical students to spend three years providing primary care services, the system is driven by generalists rather than having specialists determine how the system works. Pietroni characterized the current era in Cuba as one of medical diplomacy. While Cuba’s leadership and success on this front is commendable, the country remains ostracized politically. Today, Cuba is on par with the U.S. and U.K. in terms of key health indicators (Figure 3-2). Lessons to be learned, said Pietroni, are the importance of:

• Integrating public health and primary care;

• Doctor-patient ratio;

• Generalist emphasis on medical education;

25 United Nations Population Fund (UNPF), State of the World’s Population 2006 (except for Cuba); United Nations Development Program, Human Development Index 2006; Cuba, Ministerio de Salud Pública (MINSAP), Annual Health Statistics, 2005 & 2006.

• Collection of data at front-line sites;

• Integrating hospitals/community/primary care;

• Multi-professional approach and good interagency collaboration;

• Managerial system without professional managers;

• Extensive involvement of “patient” and public in decision making at all levels;

• Central government support – both political and economic.

He concluded that the Cuban example is the outcome of a health system that is driven by care, concern, compassion, curiosity, courage, and values. “That’s where we should start in our system…that’s what can happen, and does happen.”

Figure 3-2. Selected indicators for Cuba and the region

Source: Pietroni, based on UNPF 2006, UNDP 2006, and Cuba, MINSAP, 2005 & 200625.

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3.2 EFFORTS TO IMPROVE CARE DELIVERY IN CANADABrian Hutchison noted that together, Canada and Russia account for most of the land area in the northern hemisphere and they share certain healthcare challenges as a result. Canada has 58% of the land area and 20% of the population of the Russia Federation, with some clustering in urban areas and many people scattered throughout rural and hard-to-reach areas. This poses distinct challenges in the delivery of healthcare in general and the delivery of primary care in particular, he said. Canada has 16 separate health systems and public spending accounts for 70% of healthcare expenditures, with the federal government contributing about 30% of public expenditures and provincial governments covering the remainder. To receive federal healthcare funding, provincial governments must adhere to principles of the Canada Health Act (1984). The principles are: universal of insurance, comprehensive care, accessibility26,

portability (nationally and internationally), and public administration by public agencies on a not-for-profit basis, although delivery can be public, private, or not-for-profit. Hutchison provided a snapshot of how healthcare services are utilized in Canada among people over 15 years of age. Each month, about half of those people will have a chronic condition, around 25% will see a family physician, less than 1% will see a physician other than a family physician, and less than 0.1% will have an overnight hospital stay27. The vast majority of healthcare in Canada is provided at the primary care level, he noted.

3.1.3 The Canadian health system versus other high-income countriesHutchison provided an overview of how the Canadian health system performs relative to 11 other high-income countries (Australia, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the

26 Access is based on need, not ability to pay; there are no copays or deductibles for physician or hospital services.27 Stewart M & Ryan B. (2015). Ecology of Health Care in Canada. Canadian Family Physician May;61(5):449-53. Stewart M1, Ryan B2.

United Kingdom, and the United States). Compared to the average of those 11 countries, he reported, Canada has:

• Lower total health expenditures per capita (-15%);

• Less annual growth in total and government health expenditures, 2005-2015 (-10%, -25%);

• Fewer hospital beds and hospital days per capita (-34%, -31%);

• Fewer long-term care beds (-21%);

• Fewer MRI units and CT scanners (-41%, -40%);

• Fewer physicians and nurses (-23%, -20%);

• Higher pharmaceutical expenditures per capita (+19%);

• More GtPs per 1000 population (+12%);

• More physician visits per year (+31%), despite having fewer physicians;

• Longer wait times for primary/secondary care and elective surgery.

Hutchison then looked at healthcare quality relative to health expenditures per capita in Canada versus the other 11 countries. Canada ranks seventh in spending and ranks fourth (tied with Switzerland) in health quality. He reported a correlation between healthcare expenditure per capita and healthcare quality as measured by the health access and quality (HAQ) index, but only if the U.S. outlier is removed (Figure 3-3). He was careful not to claim a causal relationship, but suggested that the countries that spend more tend to perform better as measured by that index. He summarized Canada’s system as having a lean structure, a limited supply of specialists and nurses, a large number of general practitioners, and as performing relatively well at moderate cost.


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Figure 3-3. Health expenditures per capita vs. HAQ index

Source: Hutchison, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

3.1.4 Efforts to strengthen primary care in CanadaHutchison explained that primary care in Canada stagnated in 1980s and 1990s, partially due to a recession and substantial cutbacks in health spending. However, a new policy environment emerged with the 2003 First Minister’s Health Accord. It created $17.3 billion in federal funding over three years targeting primary care, home care, catastrophic drug coverage, diagnostic equipment, and electronic patient records. Much of that funding went to innovations in primary care delivery, he said.

Ontario is ranked highest among all Canada’s provinces in strength of primary care across seven domains, reported Hutchison, despite having one of the fewest family physicians per capita. Hutchison attributed Ontario’s performance to multiple factors, including heavier investment and a strategy to improve

the quality of primary care over the past 15 years. That strategy includes collaborative policy development with major stakeholders, particularly healthcare professionals. Participation in the strategy is voluntary for patients and healthcare providers, but physicians who elect to participate have increased income and access to enhanced infrastructure. The strategy employs multiple innovative organizational and funding models, including blends of fees for service, capitation, bonuses, and multiple payments aligned with health system objectives (there are no unitary methods of payment). Between 2002 and 2017, the percentage of family physicians using a traditional fee-for-service comprehensive-care payment model decreased from 94% to 14%. During the same period, the percentage using capitation-based blended payment models snowballed to 41% and the percentage using a fee-for-service blended payment model increased to 24%.

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Primary-care family health teams28

were developed in 2005 and, today, 20% of primary-care physicians in Ontario work in such teams or in community-health systems. Providing more medical schools increased the number of primary-care providers per capita. Other key policy initiatives in Ontario, according to Hutchison, include:

• Voluntary patient enrollment;

• Expanding the pool of primary-care providers;

• Adopting electronic medical record systems;

• Linking unattached (especially high-need) patients to primary-care providers;

• Measuring performance and providing feedback;

• Providing quality improvement training and support;

• System integration initiatives.

3.1.5 Features of high-performing primary-care systemsHutchison summarized the features of high-performing primary-care systems. Patients register with a primary-care provider who is responsible for a specific population, serving as a denominator for performance measurement. Primary care has minimal or no associated user fees at the point of

28 Family health teams comprise family physicians, nurse practitioners, nurses, mental health workers, dieticians, pharmacists, social workers, and sometimes health educators and physical therapists.

delivery and it serves a gatekeeping role. Local primary-care governance is inclusive and participatory, rather than being fractured across different agencies. This allows providers to collaborate, gives them a collective voice in healthcare planning, facilitates sharing of resources and expertise, and imbues a sense of accountability for responding to community-health needs. Payment systems for primary-care providers are aligned with health system goals, he said. For example, blended payment methods can offset some of the perverse incentives and promote alignment with health system goals. Interdisciplinary primary-care teams allow team members to focus on their own areas of expertise. Multi-functional electronic patient records are important, he said, as are performance measurement, feedback, and quality improvement support to assist physicians in professional development and improvement. Public health, community care, secondary care, and tertiary care are integrated and coordinated, and there is a systematic approach to the evaluation and spread of innovation. He presented Figure 3-4 as a schematic illustration of an integrated health system that is committed to continuous improvement toward the triple aims of improving health outcomes, providing better patient experiences, and controlling health costs.


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Figure 3-4. Integrated health system

Source: Hutchison29.

29 Adapted from Charles Kilo’s “Primary Care Oriented Health System” model by the Health Quality Ontario Primary Care Quality Improvement Team.30 Hunter Heyck, Age of System: Understanding the Development of Modern Social ScienceBaltimore: Johns Hopkins University Press, 2015.

3.3. DELIVERING HEALTHCARE TO COMMUNITIES: EXPERIENCE FROM THE NETHERLANDSWeinke Boerma spoke from his experience as an international health services researcher with his organization, NIVEL. He emphasized that community and primary-care services are an indispensable part of any comprehensive and responsive health system. A health “system,” he said, is a code word that is widely used but not very reflectively30. He defined a system as comprising ‘interdependent elements that serve specific roles to provide an organized response to the needs of the community.’ If this is not the case, he said, then it is not a system that is functioning nationwide.

Boerma defined primary care as ‘directly accessible care, prevention, and health education provided to people living at home.’ It includes: family medical care; home nursing; personal care; pharmaceutical care; general mental care; physiotherapy; and social work. Across the European region as defined by WHO (including Russia), more countries are focusing on primary care, Boerma said, because evidence suggests that it is the best way to resolve the challenges that their health systems face. These challenges include demographic transitions (such as an aging population that is more vital than in years past), changing health risks (such as lifestyle-related non-communicable diseases), and more complex demands for

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healthcare (such as people with multiple chronic diseases). More and more often, patients who have better access to health information, and are thus more discerning, are demanding outpatient and home-based care. While Boerma reported new developments in medical and pharmaceutical technology, he noted that expenditures are increasing while marginal returns on health investments are decreasing. Many countries also have shortages in health and human resources.

3.1.6 Challenges and strategies for health systemsBoerma surveyed the burden of disease in the Netherlands, which has been shaped by the aging of the population. The Dutch health expenditure as a percentage of GDP makes it the most expensive in WHO’s European region, at 12.6% (Russia is around 6%). Together, mental health disorders, cardiovascular diseases, and cancer represent the greatest burden of disease (70%) in the Netherlands. Of the total burden of disease, 13% is caused by smoking and 5% by people being overweight. He stressed that the health system must be able to adapt to this growing burden of disease through strategies that focus on prevention rather than just treatment.

Boerma outlined possible strategies for addressing these health system challenges. He called for a shift to patient-centered care, as opposed to disease-centered care, and for adopting proactive and population-based approaches integrated with “reactive” care for individual patients. He also suggested being inventive in redesigning tasks--for example, by creating multidisciplinary teams to bring down the traditional walls between primary and secondary care that prevent coordination in the treatment of chronic diseases. Better use

31 Hunter Heyck, Age of System: Understanding the Development of Modern Social ScienceBaltimore: Johns Hopkins University Press, 2015.

of information and new technology are also important strategies, according to Boerma.

3.1.7 What can strong primary care offer the health system?To explore whether these strategies for strengthening the entire health system can be driven by strong primary care, Boerma outlined ways that primary care can contribute to the system, drawing indicators from a systematic literature review to illuminate the specific functions of strong primary care (Figure 3-5). Strengthening primary care, he said, contributes to the health system in a variety of ways. First, it provides triage and first-contact care close to where people are living. However, because it is community-based, it must be relatively small-scale. Second, it offers cost-effective treatment for most conditions with more than 90% of patients receiving treatment through primary care. Third, it accommodates both individual and population approaches that facilitate the provision of preventative care. Finally, it facilitates the coordination of care provided at different points in the health system, through accountable primary-care providers who are responsible for an identified population. Among the other benefits of strong primary care institutions is the way they limit unnecessary secondary-level care. According to Boerma, published evidence31 suggests that stronger primary care is associated with better health outcomes (e.g., fewer potential life years lost and less social inequity) and better opportunities for cost containment, such as fewer avoidable hospitalizations. However, patients may not be more satisfied because they have less freedom of choice, and overall health expenditures are not lower.


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Figure 3-5. What is strong primary care?

Source: Boerma, based on Kringos et al. 201032.

32 Kringos DS, Boerma W, Hutchinson A, van der Zee J, & Groenewegen P. The Breadth of Primary Care: A Systematic Literature Review of its Core Dimensions. BMC Health Services Research 10:65. Doi: 10.1186/1472-6963-10-65.33 MacKenbach JP & McKee M. (2013). A comparative analysis of health policy performance in 43 European countries. European Journal of Public Health Apr;23(2):195-201. doi: 10.1093/eurpub/cks192.

Boerma cited a comparative analysis33

of health policy performance in 43 European countries that assessed the success of government prevention policies aimed at strengthening primary care. He reported that in terms of realizing governmental prevention policies, only Ukraine has been less effective than Russia among the countries analyzed. He noted that strengthening primary care implies changing the roles of actors in healthcare. Governance should take a leadership role in promoting primary-care measures, actively involving stakeholders, and focusing on steering rather than rowing. Care purchasers/payers should demand better value for lower cost and create incentives to facilitate this objective. Providers should take on new roles and focus on improving teamwork and networking, and patients should become more active, empowered, and health literate.

3.1.8 Monitoring primary care with the Primary Care Evaluation Tool (PCET)Boerma described the implementation of a Primary Care Evaluation Tool (PCET) developed for WHO to assess primary care in countries in the WHO European area. The analysis found that the use of information technology in primary healthcare practices was widely variable across the region. For example, the availability and use of computers for clinical records by family doctors and general practitioners ranges from around 10% in Ukraine to about 90% in Turkey. The percentages of primary care physicians involved in family planning—a critical component of primary, community-based care—also varies widely, from around 5% in the Russian Federation to 100% in Moldova. From the patients’ perspective, financial barriers can prevent access to primary healthcare. The percentage of patients who

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reported that they have delayed or abstained from a primary healthcare visit for financial reason (e.g., inability to pay for prescription medications) ranges from less than 5% in the Russian Federation to 30% in Moldova.

Boerma concluded by laying out a set of “burning issues” revealed after carrying out the PCET in ten countries. In terms of governance, there is a lack of consistent vision, weak leadership, lack of priority on primary care, inability to turn policies into practice, lack of stakeholder involvement, and no incentives for quality. The workforce has staff who are insufficiently trained for new tasks; there is resistance from medical universities and there are pervasive rural shortages. Nurses’ potentials are not sufficiently leveraged, as they are often used only for administrative tasks rather than actual care. In terms of medical education, family medicine is not recognized in most countries and obsolete methods continue to be used. Continuing medical education is also obsolete and not up to the standard upheld in the West. Medical professionals are poorly organized and lack leadership, he said. Service delivery has only limited task-shifting between secondary and primary care; there is a lack of skills and equipment and poor coordination. There are no practice information systems or software available to facilitate improved quality of care and there is no tradition or infrastructure for monitoring and evaluation of health services. In patients, there is a lack of trust and underdeveloped health literacy.

3.4 PANEL 2 DISCUSSIONReferring to Pietroni’s point about the importance of the process underlying these systems, Keshavjee emphasized that this process should involve care-giving explicitly. He noted that health system reforms have been driven by concerns over cost (which are important), but the fundamental purpose of the system is to deliver care; this is where Cuba provides an excellent example. The example from Canada speaks volumes about what is achievable, he said. A lesson to glean is that better, more accountable systems with

better outcomes are created by having better linkages with the population.

Komarov observed that today’s healthcare workforce is not trained to think clinically, as it was in the past. Primary healthcare deals with living conditions, but physicians do not want to deal with that facet. He suggested that community outreach will not be effective without appropriate follow up by healthcare providers in the community. Mark Field advocated the convergence of health systems, he noted, and clearly showed that health systems get energy from one another. He suggested that various models of healthcare should be explored to find the optimum system with community-based care as the focus, and only the HSE can accomplish this. A system of health protection is important, because nutrition, access to clean water, sanitation, hygiene, and living standards all factor into the population’s overall health status. He argued that this should be the responsibility of top leadership, because the health system’s function is specifically to provide medical services. Russia’s transition to the semi-market insurance model left the provision of medical services with a “money following the patient” principle, which he called idiotic, because providing fees for completed cases perversely incentivizes the system to increase the number of sick people, rather than the number of healthy people. Focusing on the quality of the process and activities of the system is not the same as the quality of care, he warned; quality care should be patient-oriented rather than physician-oriented.

Pietroni agreed that these challenges should be viewed in the context of the entire system and where primary care fits into secondary and tertiary care. He suggested that a key strategy, based on the experience in Cuba, would be to change the medical education system such that doctors and nurses are focused on family and community care from the beginning (and not allowing them to specialize until they complete three years in primary care). He contended that this creates a shared vision, shared organizational structure, and shared commitment to delivering healthcare as close to communities as possible.


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Farmer also commended the Cuban system, noting that the biggest national delegation involved in responding to the Ebola outbreak was the Cuban team. The biggest issue he observed, as both an admirer and coworker, is that they are not magic—”you still need money.” For example, there were more Cuban physicians and laboratory technicians in rural Haiti than Haitians; the same also held true in Liberia. They had the staff and systems, but without the stuff and space, they could not make the broken, impoverished Haitian system work; they needed support from PIH because they could not do it alone. He observed that the pathologies which make up the burden of disease in Ethiopia and Rwanda today are no different than those in Finland in the 19th century or elsewhere in Europe later on. What is happening in Africa now is actually a decline in those pathologies, he noted. When there is a rollout of programs for the top treatable diseases (syphilis, HIV, TB, and malaria), he explained, the “epidemiological transition” to non-communicable diseases happens very rapidly: chronic conditions increase as infectious diseases decrease. Attacking the problem of neonatal mortality in the first 30 days of life, for example, requires different staff, stuff, space, and systems. He predicted that what is happening in those countries is not unique and will continue to mirror complex transitions that have happened elsewhere in the world.

Pietroni compared two experiments. One was a well-funded study sponsored by the Gates Foundation in Malawi and the second was the Cuban model used in East Timor. In Africa, European countries are enticing local expertise and health providers away from their home countries at increasing rates, he warned. Malawi was impoverished by the loss of its professional staff, so the Gates Foundation funded doctors in Malawi to stay there for five years at the same salaries they would get in Canada or Europe. The healthcare results were astounding during that period, he reported, but unfortunately, the staff emigrated again when the funding ended. In East Timor, the Cubans went to rural areas to identify young people who would be flown to

Cuba and trained as healthcare professionals. These recruits were then able to return home to East Timor and take over the rural primary healthcare centers that the Cubans had established. This process took ten years, illustrating how the key ingredient to achieving impact is time. He cautioned that none of these problems can be resolved during the political lifetime of a single government, which is usually followed by another government that dismantles the previous administration’s measures.

Komarov added that the health sector globally is a system of social equalization: we are all equals when we face death and disease. He argued that Russia is currently wasting money by investing in healthcare and expensive technologies that are only accessible or appropriate for a tiny fraction of the population.

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4 Models for improved outcomes in RussiaDuring the third panel, speakers explored models for catalyzing improved health outcomes in Russia. Irina Vasilyeva, senior TB physician at the Russian Ministry of Health and director of the phthisiology (tuberculosis) division of the Central TB Research Institute at First Moscow State Medical University, provided an overview of the TB situation in the

Russian Federation. She also discussed the role of advanced organizational technologies in addressing the problem of tuberculosis. Dr. Irina Gelmanova, project consultant at PIH, spoke about developing a spectrum of care delivery by drawing upon experience in Tomsk, Siberia.

Figure 4-1. TB incidence and mortality in Russian Federation per 100,000 population, 1970-2016

Source: Vasilyeva, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

4.1 OVERVIEW OF THE TB SITUATION IN THE RUSSIAN FEDERATION

Irina Vasilyeva explored the role of advanced organizational technologies in addressing the problem of tuberculosis in Russia. She explained that after the first TB drugs were developed, TB declined in Russia as it did worldwide. However, in the 1990s there was a surge in TB-related mortality and morbidity in Russia due to political and social upheavals. The system of TB services had collapsed, she explained, so TB began spiraling out of control as the rate nearly tripled. At beginning of 21st century, steps were taken against TB that drove

a decrease in TB mortality and morbidity, said Vasilyeva. In 2016, the rate of TB incidence was 53.5/100,000 and the rate of TB mortality was 7.8/100,000. However, she noted that the rates have not yet fallen as far as they had in the 1990s (Figure 4-1).

Vasilyeva reported that today, there is wide regional variation in TB morbidity and mortality across Russia’s federal districts, with the highest rates in the far East and lowest rates in the North West. In Siberia, high rates of TB are associated with imprisonment and the climate, as well as other factors. Despite recent declines, Vasilyeva said, TB morbidity and mortality rates remain high in Russia compared to other


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countries and there is much work to be done to achieve the desired outcomes (Figure 4-2).

34 World Health Organization. (2015). Global Tuberculosis Report 2015. Geneva: WHO.

Figure 4-2. Global TB mortality rates, 2015

Source: Vasilyeva, based on data from WHO 201534.

Vasilyeva explained that MDR-TB and HIV coinfection is a primary obstacle to achieving desired TB outcomes. Since they began registering TB cases at the end of the 1990s, rates of MDR- TB have increased every year among both initial and retreatment cases. An estimated 480,000 people have MDR-TB and XDR-TB worldwide, she reported, and the countries with the highest burdens of MDR-TB are India, China, and the Russian Federation.

In 2000, there were roughly 14,000 MDR-TB patients in the Russian Federation, which more than doubled to over 37,000 patients in 2014. In the Russian Federation, around a quarter of new pulmonary TB cases have MDR-TB—which dwarfs the rate of about 3.5% worldwide—as do about half of previously treated cases, which is more than double the rate of 20.5% worldwide (Figure 4-3).

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Figure 4-3. Proportion of new pulmonary TB cases with MDR in the Russian Federation, 2006-2015

Source: Vasilyeva, based on data from Russian Government Form 7-TB.

TB-HIV coinfection is also on the rise in the Russian Federation, according to Vasilyeva. She attributed this largely to the increase in the number of patients with HIV. Between 2009 and 2015, the proportion of patients with TB-HIV

coinfection among new cases jumped from 6.5% to 17.3% (Figure 4-4). The proportion of patients with TB-HIV coinfection among follow-up TB patients also increased from 5.5% to 15.2% during the same period.


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Figure 4-4. Proportion of patients with TB-HIV coinfection among new cases in the Russian Federation, 2009-2015

Source: Vasilyeva, based on data from Russian Government Form 33.

35 WHO 2015.

Compared to Brazil, India, and China, said Vasilyeva, treatment effectiveness is low in the Russian Federation for both new and relapse cases of TB, as well as for MDR-TB cases and XDR-TB cases. In 2015, treatment success rates were 70.7% in new and relapse TB cases, 47.6% in MDR-TB cases, and 26.7% in XDR-TB cases35.

This is somewhat puzzling, she said, because treatment outcomes are high in the most advanced clinics that deliver effective regimens to adherent patients. An analysis generated several reasons for these poor treatment outcomes. These include the prevalence of MDR-TB, XDR-TB, and TB-HIV coinfection, as well as late diagnosis of drug resistance and insufficient infection control. Patients’ inability to adhere to treatment is a key contributing factor that further drives the spread of MDR-TB bacteria infection in healthy people, she noted.

4.1.1. Russia’s national plan to detect, treat, and prevent TBVasilyeva explained that Russia has developed a program aligned with WHO’s global strategy to end TB by 2030. In the Russian Federation, they have adopted a patient-centered approach to TB detection, prevention, and treatment with a focus on attending to patients’ motivation and awareness. Strategies include improving prevention in risk groups, detecting TB early, using early diagnostics, treating effectively, supporting patients in adhering to their treatment, and addressing TB-HIV coinfection.

Improving adherence is a key pillar of the national program, said Vasilyeva. They have created targeted programs for the social and psychological support for TB patients aimed at improving treatment adherence, particularly in social groups that represent around 42% of TB cases in Russia. These at-risk groups include the homeless population, refugees, migrants from regions with high TB incidence,

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penitentiary populations, people living with HIV, and chronic alcoholics. A specific component of the national TB program has been the development of outpatient care system (within the primary-care system) to enhance the motivation of TB patients to continue treatment when they are not hospitalized, she said. As a result, treatment discontinuation among new cases and relapses decreased by 7% in a 2013 patient cohort.

Vasilyeva noted that in 2017, Russia would be hosting the Global Ministerial Conference “A Mulitsectoral Response to End TB in the Sustainable Development Era.” Almost 200 WHO member states will convene to consolidate the efforts of the WHO Member States in taking effective measures to eliminate tuberculosis in the context of multidisciplinary, multisectoral approaches and in accelerating the progress toward the health-related Sustainable Development Goal target of ending the tuberculosis epidemic by 2030. Interagency delegations will include representatives from the arenas of social policy, finance, and security (among others) in addition to representatives from ministries of health, because TB is a cross-sectoral issue.

4.1.2 Successes in Orel, Voronezh, and Arkhangelsk regionsThere are 53 regions in the Russian Federation with established systems of social support for TB patients provided at the expense of the regional programs36. The Orel region has implemented a pilot project that has achieved good outcomes through both inpatient and outpatient TB care, she said. On the inpatient side, the Orel TB Dispensary runs a dedicated TB hospital as well as a TB department at the regional hospital. The dispensary also runs outpatient departments for adults and children, day-care clinics, and home-based care.

Central hospitals in the regional districts provide outpatient care in TB units and district first-aid stations. Home-based ambulatory TB treatment is available for patients with limited mobility, socially vulnerable patients with low

36 Based on 2015 data from the Federal Research Institute for Health Organization and Informatics of the Ministry of Health (FRIHOI).

motivation for treatment, patients who refuse to visit medical facilities for drug administration, and alcohol-addicted patients. A mobile team of medical workers delivers TB drugs to patients’ homes. Patients receive physician visits at home once a week or as needed, but receive their regular examinations at the TB dispensary. To motivate them to adhere to treatment, patients receive further social support through regular delivery of nutrition and sanitary packages.

Vasilyeva reported that the program has achieved successful treatment outcomes in 87.9% of TB patients receiving home-based care and in 73.2% of MDR-TB patients receiving home-based care. The program has also impacted the overall epidemiological situation in Orel. By 2013, TB incidence had dropped to 37.9/100,000 (compared to the national average of 63/100,000) and TB mortality dropped by 65% to 2.2/100,000 (compared to the national average of 11.3/100,000). The number of MDR-TB case decreased by almost 250 percent between 2003 and 2012. Vasilyeva noted that outpatient treatment is significantly less expensive than inpatient care. As of 2016, the cost of one day of treatment in the Orel Region’s TB dispensary was around 400 RUR for treatment at home, compared to almost 1900 RUR for treatment in an inpatient TB unit.

The Voronezh region has also seen improvements in TB care, according to Vasilyeva. Approaches for managing treatment include the use of Rapid DST(Drug Susceptibility Testing) before treatment, drug-susceptibility-based treatment, proper infection control, and directly observed treatment. Funding from the region’s budget for social support programs for TB patients with good outcomes was doubled in 2013-2014, with 442 patients receiving daily food packages (at a cost of $95USD per patient); 417 (94.3%) of those patients completed or continue their TB treatment effectively. Within the program’s patient-centered approach, there are mobile teams that find and visit TB patients to provide social support. This has resulted in good outcomes, even for challenging cases. As of 2014, the incidence of TB in the Voronezh


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region had dropped by 52.9% (33.0/100,000) since 2005 (Figure 4-5). Another critical impact of the program has been reducing the reservoir of MDR-TB in the region. MDR-TB rates in

Voronezh dropped from 59.0/100,000 in 2010 to 18.8/100,000 in 2014, which is lower than the overall rate for the Russian Federation of 24.8/100,000 in 2014.

Figure 4-5. Main TB epidemiological indicators in the Voronezh region

Source: Vasilyeva, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

The Arkhangelsk region implemented a pilot project called “Harmony” in 2011, said Vasilyeva. The goal of the project was to promote treatment adherence and treatment completion among patients who do not comply with conventional forms of treatment. Patients receive delivery of their treatments at their homes or in other places outside of hospitals. The region previously had high TB incidence

and mortality rates, but as a result of the pilot program, the rates have dropped and are now lower than the national average rates. She reported that of the 566 total TB cases registered in the civil sector in 2011, 81.8% (381/465) of new cases were cured and 70.9% (66/93) of relapse cases were cured. The pilot project also achieved very good outcomes in the penitentiary system, she said (Figure 4-6).

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Figure 4-6. TB Incidence including the penitentiary system (new cases and relapses) and mortality in Arkhangelsk Region, 2001-2012 (per 100 000 population).

Source: Vasilyeva based on data from Andrey Maryandyshev and Elena Nikishova.

37 Shin SS, Pasechnikov AD, & Gelmanova IY, et al. (2006). Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia, IJTLD 10(4):402-408.

4.2 DEVELOPING A SPECTRUM OF CARE DELIVERY: EXPERIENCE IN TOMSKGelmanova reflected on the experience of PIH in Tomsk, Siberia, as an example of developing a spectrum of care delivery. Tomsk has a population of 1 million and a geographical area roughly the size of Poland. Much of the population lives in rural areas, some of which are swamplands that can only be reached by helicopter and only during three months of the year. When PIH arrived in Tomsk in 2001, susceptibility testing revealed that 40.6% of TB patients had MDR-TB, which requires a two-year course of treatment with drugs that have many side effects—as opposed to the 6-month regimen used to treat drug-susceptible TB (DS-TB).

PIH’s main goal was to achieve good treatment outcomes, said Gelmanova, thus a diversity of approaches was employed from the outset in terms of therapies and strategies. For example, they provided food packages and other bonuses to encourage daily treatment, they cooperated

with Red Cross volunteers, and they provided home-based care centers. They initially planned treatment in inpatient clinics for patients in rural areas, but they soon realized that it was not possible to convince people to stay in the inpatient clinics, because many patients—often the most complicated patients with social issues—were not willing to stay in the hospital. They began to organize treatment for patients at home, she said. Additional motivation for patients came from the food packages they received, which were funded by Global Fund.

The outcomes were initially surprisingly positive, remarked Gelmanova. In prisons, there was an 80.8% rate of treatment success (cure) between 2000-2004, a time when the WHO average treatment success rate was 50% worldwide. In the civilian-sector cohort, the treatment success rate was 77.0%37. However, adherence became a pressing issue beginning in 2004, when the treatment failure rate climbed to 28.6%. Home care was provided through a mobile hospital, but it could only see 50 patients for brief visits. They tried incentives such as food packages as well, but a variety of factors continued to pose


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barriers to treatment adherence. Social barriers included poverty and family problems; patient-dependent factors included lack of interest in treatment, alcohol and drug use, homelessness, mental illness, unemployment, and being an ex-prisoner.

To work toward removing those barriers to treatment, they implemented the “Sputnik” model as a programmatic solution to deliver successful care, though a system of close accompaniment for patients who need extra social support. They provided social services, food packages, drug and alcohol counselling, psychologists, and support for patients’ families. “We took responsibility from the patients and

38 Gelmanova IY, Taran DV, Mishustin SP, Golubkov AA, Solovyova AV, Keshavjee S. (2011). ‘Sputnik’: a programmatic approach to improve tuberculosis treatment adherence and outcome among defaulters. IJTLD, Oct;15(10):1373-9. doi: 10.5588/ijtld.10.0531.

put it on ourselves,” said Gelmanova, who emphasized that criticizing or blaming the patient does not help. Patients selected to take part in Sputnik had prior problems with adhering to treatment after leaving the hospital where they had been treated initially. The outcomes for the cohort of 53 MDR-TB patients were excellent: 27 patients (71.1%) completed treatment and only two patients (5.3%) failed to complete treatment38.

Figure 4-7 shows the overall population-level effect; there is a significant reduction in Tomsk compared to the entire Russian Federation.

Figure 4-7. Incidence of tuberculosis in Tomsk region and in the Russian Federation (per 100,000)

Source: Tomsk Oblast TB Services

Many people have questioned the cost of the program, said Gelmanova, and it is indeed very expensive. A retrospective analysis of more than 22,000 patients older than 17 years who

started treatment for pulmonary TB in the civilian sector in 2011 compared the outcomes and cost of treatment for patients in the Tomsk program versus patients in other parts of Siberia. Funding

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provided by the government, PIH, and Global Fund was assumed to be the main difference in cost of treatment between Tomsk and the Siberian okrug. TB drugs cause serious side effects including nausea, diarrhea, mental health issues, and suicidal ideation. In the traditional Russian model, outpatients must buy their medications themselves, but the majority of patients in Tomsk had free medications to ameliorate those side effects and comorbid conditions. Social support in the rest of Siberia is very limited compared with Tomsk, where more than 90% of ambulatory care patients receive daily food deliveries. Assistance with transportation costs is also provided. In Tomsk, patients at highest risk of defaulting treatment receive treatment at home—usually twice a day—by the Sputnik mobile team, while in other Siberian regions, patients at risk must travel to the point of treatment of their own volition.

Gelmanova reported that treatment outcomes were very good in Tomsk, which had a treatment success rate of 90.9% (390/429) versus 62.8% for the entire Siberian region. For patients with MDR-TB, the treatment success rate was 61.7% in Tomsk versus 45.5% in the Siberian okrug. The cost of treatment in Tomsk, excluding external financing, was US$4,581 for DS-TB and it was US$15,721 for MDR-TB. Those treatment costs are roughly the same for the Siberian okrug, at US$3,894 for DS-TB and US$13,694 for MDR-TB. In both Tomsk and the Siberian okrug, treatment costs about US$28 per day for DS-TB patients and about US$36 for MDR-TB patients. The complete costs for treating a DS-TB case were $6,301 in Tomsk versus $8,097 in the Siberian okrug; the complete costs for treating an MDR-TB case were $34,112 in Tomsk versus $42,216 in the Siberian okrug.

Even though the cost of treating TB in Tomsk is higher than in the Siberian okrug, Gelmanova reported, Tomsk is actually less expensive in terms of overall treatment cost per case. Tomsk is much less expensive when the additional costs of treating people who become infected with TB by non-treated TB patients are taken into account. Outpatient costs for up to two visits per day were lower than the cost

of inpatient hospital treatment. The patient-centered approach used in Tomsk required an additional investment of US$687 per case over the cost of treatment in the Siberian okrug. However, because the program was able to achieve a higher treatment success rate, the Tomsk model is ultimately cost-saving—given the cost per DS-TB patient cured in Tomsk (US$6,301) versus Siberia (US$8097)—and it provided greater value for the money invested. She emphasized that the higher cure rate is tantamount to less transmission of TB to patient’s families and communities. This is evidenced by the steeper reduction in the incidence of TB between 2000 and 2015 in Tomsk (50%) versus the Siberian okrug (10%).

4.3 PANEL 3 DISCUSSIONGiven that Russia is so big and diverse, Komarov said, the outcomes from the Sputnik model will need to be supplemented with more evidence before they can be applied country-wide. He asked about the role of general practice in treating TB, and how best to address the problem of ex-prisoners who spread the disease upon their release. Vasilyeva replied that everything starts at the primary healthcare level, including preventative screenings and examinations for adults and children (they are dealing with issues regarding screening validity). As a result of the screening, they can identify “small” TB that is not infectious. The infectious form is more common in patients who are more difficult to get in for screening, for example, because they are marginalized. The Ministry of Health provides methodological guidance and support in developing programs for monitoring patients. She noted that some regions are receptive while others are very resistant to working with the Ministry: “Where there is good teamwork in the region, there is good success; where there is no teamwork, less so.”

Vasilyeva conceded that there are many gaps in the system that they are trying to resolve. For example, if a patient comes to the inpatient clinic several times, it could be misrecorded as a double count. In regions where the TB service does screenings, there is coverage in rural


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populations through a regional health committee that drives around with a portable fluoroscope and diagnoses people. She also agreed that the penitentiary populations are a big concern. Everyone who enters prison undergoes a mandatory TB examination that is repeated every 6 months and followed by treatment as needed. TB patients who are released while undergoing treatment are referred to the local TB service in the region where they are registered to complete treatment. Today, patients are allowed to move to different

regions, unlike in the past, when they had to obtain a regional certificate of release. Half of such patients are lost to follow up because they left their place of registration, she reported. People with more severe forms of TB disease are released earlier from prison and these cases are often incurable, which creates a serious risk of infection for people with whom they come into contact. She suggested that new mechanisms will need to be implemented to address this.

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5 Toward a healthy futureDuring the fourth panel, speakers were asked to look toward a healthy future. Vasily Vlassov, professor, Department of Healthcare Administration and Economy, HSE, imagined a reorganized Russian model of care delivery with a priority placed on improved palliative care. Salmaan Keshavjee, Director of the Center for Global Health Delivery–Dubai, described the Zero TB Initiative, which uses TB as an entry point to improved ambulatory care delivery.

5.1 IMAGINING A REORGANIZED RUSSIAN MODEL OF CARE DELIVERYVasily Vlassov, a long-time advocate of reforming the health system in Russia, reflected that despite a national project to discuss such reforms, those fundamental changes have not yet been achieved. Like many other countries, Russia has experienced an epidemiological transition toward diseases related to its aging population. His presentation focused on palliative care as a healthcare model. As of 2015, 24% of people in Russia were beyond working age and this demographic proportion is increasing in Russia, as it is around the world.

Vlassov pointed to the traditional distinction in healthcare between the curative model, which is focused on healing and restoring the patient to health, and the palliative model, which is focused on improving a patient’s quality of life when healing is not feasible or possible. However, he argued, this distinction is actually a false dichotomy. People live longer today than in the past and most people will eventually develop chronic conditions; many diseases that used to be fatal can now be treated. For example, millions of people with HIV are undergoing palliative treatment and living decent lives. On the other hand, some diseases which in the past were only suitable for palliative treatment can now be cured, like hepatitis C.

Another key distinction, according to Vlassov, has been drawn between acute care and palliative care. Acute care is focused on prolonging the lives of patients who have acute injuries or diseases, or severe states in the course of a chronic disease. Palliative care, in contrast, is focused on improving a patient’s quality of life in the course of a chronic disease, but without the expectation that the patient will return to full health. WHO defines palliative care as “the active total care... of patients whose disease is not responsive to curative treatment.” The common understanding in palliative care is that chronic care and care of advanced illness should be integrated: acute and curative approaches should be used appropriately and locally. This is what the approach should be, he argued, but in the modern approach to palliative healthcare, these efforts are actually concentrated toward the end of a patient’s life. The attitude toward incurable disease is also changing, said Vlassov. Technological and therapeutic advances can make it difficult to differentiate when one type of care should end and the other type should begin. For example, chemotherapy is used more actively during the final stages of cancer care because today, it is less toxic and poses less difficult decisions for physicians and patients.

Vlassov characterized healthcare in Russia today as “the apotheosis of the curative model.” People of middle/working age receive better access to healthcare, but they are the ones who need healthcare the least. He explained that Russian law does not allow patients to make the decision to refuse treatment for certain diseases. “This is the function of the apotheosis of the curative model,” he said, “which is enshrined in law.” Clinical trials have demonstrated that palliative care for some chronic conditions extends life at least as well as acute care does, but palliative care offers patients a higher quality of life. Palliative care should be started at the onset of a condition, he said, not just at end of life.


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Chronic care and care for advanced illness should be integrated, and both acute care and curative care should be used appropriately and only to the necessary extent. Most patients have problems that need curative care as well as problems that warrant only palliative care.

Vlassov looked at the history of palliative care over the previous 50 years. In 1967, Cicely Saunders created the first hospice and the 1980s saw the emergence of opportunities to help patients with terminal sedation. In 1984, the U.S. recognized patients’ rights to create advanced care directives about their end-of-life treatment, the Netherlands legalized euthanasia, and the American Medical Association approved withholding or withdrawing treatment from patients in permanent comas or those who are close to the end of life. In 1990, Jack Kevorkian made headlines and drew national and international scorn for his provision of assisted suicide; he was ultimately imprisoned in 1998 and he had a huge impact on a global scale. In 1997, Oregon passed the Death with Dignity Act in a political move that was ahead of the curve, he noted. In 2008, Luxembourg legalized physician-assisted suicide and euthanasia and by 2010, a number of other countries had done the same to recognize the suffering of patients at end of life.

Vlassov emphasized that Russia does not necessarily need to legalize assisted suicide or euthanasia, but argued that Russia has nearly “lost it all” as other countries move toward such measures. In 1994, the first hospice opened in Moscow but in 2011, Russian healthcare legislation banned any death support or withholding of treatment from patients at end of life. In 2015, any suicide-related discussions (e.g., procedures, implications, justifications,

etc.) were banned in Russia. Because debate is not even allowed, it is an issue that most people in Russia are not aware of and do not understand. He remarked that recently, a woman wrote to a newspaper asking Putin to punish the pediatricians who offered her the possibility to watch her dying newborn pass away. In Western countries, he said, parents dream of being able to be with their child in his or her final moments; in Russia, the woman asks Putin to punish the doctors for this. It is not her fault, he said, but it demonstrates how far Russian society is from an open discussion of these issues.

Vlassov presented a map (Figure 5-1) that illustrates access to palliative care worldwide, noting that Russia and the other post-Soviet countries provide very limited access to pain treatment for their populations. This is a result of ideology, he said, because it was forbidden to discuss a human life that was under public control. A 2016 study found that in some Russian regions, it was not legal to procure opiates for pain management and added that terminal care in Russia is patchy more generally. In the Russian system, patients have limited self-determination and their families have very little input into the treatment of their family members in intensive care. Community participation in healthcare is non-existent and primary care is virtually powerless in this arena. More affluent regions, such as Moscow, have created a specialized workforce to address the demands of curative and palliative treatment for the aging populations. Vlassov characterized this as bizarre and as a poor, inequitable use of resources.

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Figure 5-1. Who can access pain treatment?

Source: Vlassov, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

39 Anon. What is GRADE. BMJ Clinical Evidence. Available at http://clinicalevidence.bmj.com/x/set/static/ebm/learn/665072.html.

Initiatives taken so far, said Vlassov, include the Sheffield model of palliative care in oncology, which is also called comprehensive care. This model promotes the idea that palliative care is important from the very beginning to the very end of treatment. Palliative therapies are included alongside rehabilitation, social work, chaplaincy, dietetics, and other efforts that support the patient and the family, while the oncologist treats the disease with curative and life-prolonging therapies.

Vlassov quoted the British Medical Journal’s GRADE system, which is used to make judgements about the quality of evidence and the strength of recommendations regarding medical interventions. “We focus on clinical outcomes that matter to patients — meaning those outcomes that patients themselves are aware of in relation to their condition — for example, symptom severity, quality of life, disability, and survival.”39 He noted that

survival comes last in this list of criteria, and suggested that this illustrates how much progress is still left to make in Russia. A significant shift occurred in medicine by the end of the 20th century that has been virtually ignored in Russia.

Vlassov offered his vision for the best standard of integrative care. The best form of healthcare is a cure, whenever possible. Case management should be guided by patients’ preferences and take quality of life into account; patients should be involved in informed decision making about the goals of their treatment, with symptom control and optimizing quality of life as priorities. Treatment linked to end of life is the point at which these overarching goals of treatment converge and the focus on palliative care should be increased. If palliative care is not well-organized palliative care, for example, you may have a child being treated for cerebral palsy, and the doctors are constantly trying to cure the patient while neglecting other parts of


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care. Palliative care should be the framework for healthcare throughout the patient’s life, he emphasized.

Finally, Vlassov considered the best strategy for integrating care. Hospice and hospital-based palliative care is being actively developed in industrialized countries, but it is expensive and not always effective in addressing the real problems faced by patients and families. In the U.K., the number of palliative care physicians is more than oncologists and neurologists combined40: “that’s how it should be in Russia, too.” Palliative care should be implemented in primary care, he said, because primary-care providers are better equipped for the role integrating of integrating curative care and palliative care. This integration must be community-based and not purely medical, especially for preventative interventions and palliative care. As to the feasibility of this, Vlassov argued that it is achievable, but that people in Russia must first go through the process of formally recognizing palliative care as a human right, which means a person’s right to bodily autonomy and full choice of treatment.

40 Doyle D. Palliative medicine in Britain. Omega (Westport). 2007-2008;56(1):77-88.

5.2 ZERO TB INITIATIVE: USING TB AS AN ENTRY POINT TO IMPROVED AMBULATORY CARE DELIVERYSalmaan Keshavjee focused on the practical implementation of models for improving outpatient and ambulatory care delivery. He noted that the TB community is already delivering care at the community level—where patients live and work—and suggested that such models may provide an entry point to care delivery for other diseases in Russia and elsewhere. In many countries in the West, he said, TB is does not pose a serious problem; while other countries struggle under high burdens of TB. “Poverty is a driver of TB and TB is a driver of poverty,” said Keshavjee. Although TB has been treatable with antibiotic therapy since 1947, and curable since the early 1950s, the incidence of the disease is declining worldwide at a painfully slow rate. (Figure 5-2). Meanwhile, TB kills nearly two million people per year and is the leading infectious cause of death of adults worldwide, and the leading killer of people with HIV. Keshavjee lamented the troubling sense of complacency and acceptance about this global status quo and explained that the TB problem is linked both to money and to care delivery.

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Figure 5-2. Global tuberculosis incidence declining only 1.5% per year

Source. Keshavjee based on data from Raviglione et al 2012.

5.2.1 What is achievable? Lessons from Alaska, New York City, and TomskKeshavjee asked the group to explore what is actually achievable in the world of TB. He described a model of community-based delivery of TB care in Alaska during the 1950s and 1960s. During that period, rates of TB among the Eskimo people in the eastern part of Alaska were extremely high, with a prevalence of around 2,000 per 100,000 people (comparable to rates in a Russian prison today). In some areas, a quarter of infants became infected in the first year of life and between 1953-1956, annual mortality from TB was 282/100,000 population. In the 1950s, the U.S. government started a

program to treat active cases of TB on an outpatient basis at the community level. After screening everyone in the community using chest X-ray and treating everyone with the disease, they soon realized that treating and curing active cases was insufficient because new cases kept emerging. To address this, they decided to try using isoniazid prophylaxis therapy for household contacts who did not yet display signs of active disease. In 1957, a randomized-control trial was initiated to test the effectiveness of this strategy. Besides screening people for active disease, they had to find others who were living in households with people who had active TB but did not themselves have active disease. They then had to treat those people, who were otherwise


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healthy, with 6-9 months of the antibiotic isoniazid. Around 40,000 household contacts without TB disease were randomized to receive isoniazid prophylaxis or a placebo and were followed for almost 20 years. Rates of TB in the intervention group were less than half of the control group who did not receive prophylaxis, with a 68% risk reduction attributable to isoniazid prophylaxis. Those who had received a 6-9 month prophylactic course of isoniazid had a reduced risk of TB for the next 19 years41. Keshavjee then turned next to the example from New York City. The city experienced a resurgence of TB cases in the 1980s, with rates increasing sharply and peaking at 3811 per 100,000 population in 1991. The New York City Department of Health and Mental Hygiene implemented a program of active case-finding and treatment

41 Comstock GW, Baum C, Snider DE. Isoniazid prophylaxis among Alaskan Eskimos: A final report of the Bethel isoniazid studies. Am Rev Respir Dis 1979;119:827-830.

for all forms of TB and TB infection, including post-exposure prophylactic treatment and contact tracing. Obviously, population-level screening was not a feasible option, as it was in Alaska. Instead, they focused on targeted case -finding, especially among vulnerable populations (like the homeless) and supporting those people through treatment on a daily basis by deploying teams of nurses on the ground. The number of TB cases dropped dramatically and by 2013, there were only 656 cases per 100,000 (Figure 5-3). He also noted the success of the program of ambulatory care delivery in Tomsk Oblast, Siberia, which drove a rapid decline of over 50% in the TB notification rate and 80% in mortality in the 2000s (as described in Gelmanova’s presentation [Section 4.1]).

Figure 5-3. Tuberculosis Cases and Rates New York City: 1982-2016

Source: Keshavjee, based on NYCDHMH 2016.

5.2.2 The Zero TB InitiativeKeshavjee highlighted the disparity between the unacceptably slow decrease in rates of TB worldwide and the rapid decreases achieved by the programs in Alaska, New York City, Tomsk, and elsewhere. There are common threads among those effective programs,

he said. They search actively for people with TB disease and their contacts and test them properly. They treat effectively and support patients through treatment. They prevent exposure to TB and treat people who have been exposed with preventative therapy. Each step is complex, he conceded, but in an

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effective, comprehensive care program all of the steps are carried out at the same time, within a system of care that is delivered to patients in the communities where they live and work. To tackle TB globally, Keshavjee called for targeting specific cities and small provinces to create ‘islands of elimination’ where local efforts and networks are focused on community-based delivery. “Everywhere you do this comprehensive package, and you deliver care, you bring down rates of TB,” he said.

The Zero TB Initiative arose out of the realization that these programs were able to deliver care locally due to smaller administrative units. Thus, the Initiative focuses on cities, districts, and small provinces instead of trying to tackle TB at a global level, which entails the daunting task of trying to convince countries to change their national systems and build primary healthcare at the national level and care delivery networks. By focusing on these smaller administrative units, Keshavjee said, “you can actually do things, you can make changes and see what works locally and what doesn’t.” He noted that for years, PIH has been successfully working with these small units, building them up, and creating networks for delivery. To apply this model to TB care, the aim of the initiative is to create a platform for high-quality, community-based care that is comprehensive—that is, simultaneously working to search for, treat, and prevent TB at the local level in cities, districts, and smaller

administrative units. The platform should serve as a link between health systems and the communities where patients live, he said.

At its simplest level, Keshavjee explained, the Zero TB Initiative is a strategy for addressing TB from a community-based health delivery platform (Figure 5-4). Cities are ideal units of change, he said, because they act as incubators for learning and for healthcare delivery innovation. Cities are home to 60% of the world’s population, they have their own resource bases, and they can easily link the public and private sectors. Cities generate 80% of the global GDP, with the world’s 750 biggest cities accounting for ~57% of the global GDP. A number of cities have already joined the initiative, he reported (Figure 5-5). In Havana, for example, they have built upon the Russian system of polyclinics by adding neighborhood clinics (“consultorio”) staffed by doctors who know all of their patients’ households. Doctors based in hospitals work one day per week in polyclinics and in consultorios, providing a direct link from the clinic all the way down to where patients live. New York City uses a different system, with teams of healthcare providers that work on the ground with patients. Other cities that have joined the initiative include Chennai in India, Karachi in Pakistan, Durban in South Africa, Ho Chi Minh City in Vietnam, five cities in Eastern Europe, and hopefully, soon 22 Chinese cities will begin pilots.


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Figure 5-4. The Zero TB Initiative

Source: Keshavjee, Presentation at Outpatient Care Delivery in the Russian Federation: Creating a Platform for Improved Health Outcomes 2017

Figure 5-5. Zero TB Initiative Alignment Matrix (Early Assessment)


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Keshavjee noted that representatives from many of those cities say that TB is not a bigger problem than, for example, diabetes or asthma. He characterized 21st century medicine as not only a scientific endeavor, but a caregiving endeavor. The challenge for medicine at the dawn of the 21st century, he argued, is how to effectively deliver the fruits of medical science to populations that will benefit. Doing so requires having moral clarity as well as effective care-delivery systems in place. Caring for patients with MDR-TB, for example, requires a complex health intervention with good systems in place. Patients sometimes experience adverse events from treatment that require specialist care linked to patients’ households. Almost 80% experience nausea and vomiting and almost half have diarrhea every day; a few experience potentially fatal effects, such as low potassium and liver damage. TB care systems have succeeded in delivering this support and care to patients, he remarked. In Tomsk, they found that patients tend to need a great amount of assistance at the outset, but then the side effects subside; approximately 65% of adverse events occurred in the first 6 months. They devised solutions to address this, including:

• Improvement of facilities;

• Transportation assistance for patients and health workers;

• Choice of treatment site;

• Food assistance for patients;

• Aggressive management of adverse events;

• Treatment at home for patients who are not ambulatory or who live too far away;

• The use of enablers and incentives;

• Social assistance for patients.

5.2.3 Prevention and Access to Care and Treatment (PACT) project (Boston, USA)Keshavjee reminded participants of the situation at the dawn of the HIV epidemic.

When ART drugs became available in 1996, it gave rise to questions about whether patients would be able to adhere to lifelong therapy. In 1999, PIH started a program in Boston called Prevention and Access to Care and Treatment (PACT) to address adherence problems among the many patients who struggled to remain on treatment. Barriers faced by people receiving care for HIV include substance use, mental health issues, domestic violence, chronic illness, poverty, homelessness and unstable housing, and isolation or stigma. “This is a programmatic issue,” Keshavjee noted. “We know that patients have a difficult time staying on treatment. We could blame the patients and walk away from it, but that doesn’t solve the HIV problem.”

Under the direction of PIH affiliate Heidi Behforouz, PACT used community-health promoters to work with marginalized HIV patients in order to improve their access to and utilization of care. These health promoters/peer prevention leaders worked in partnership with healthcare providers and social service personnel to improve quality of care. Ultimately, the health promotors became specialists in making sure that health delivery actually happened. Given that “we can’t do everything for everyone,” the strategy was to differentiate patients’ respective levels of need using an algorithm. In low-intensity care, patients had monitored self-administration with monthly health promotion, in moderate-intensity care, the patients received weekly health promotion, and in high-intensity care, patients took part in the DOT-Plus initiative. Patients were monitored regularly, and many patients shifted among the intensity levels as their needs changed throughout the treatment course.

DOT specialists visited patients in their homes 7 days a week, 365 days a year when needed. Health promoters were recruited from the affected community, with some being past PACT participants, and they received extensive curricular-based and field-based training at the onset plus 4-5 hours of weekly training and supervision. They helped patients in simple ways that served as the “glue” between


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patients, clinical services, and social services, such as: accompaniment to appointments; ongoing communication regarding patient progress and needs; facilitating multi-provider meetings; and serving as the point of contact for patients. Rates of non-adherence among patients who took part in the program dropped to almost zero.

5.2.4 TB systems as an entry point for chronic care systemsKeshavjee asked whether these models from TB and HIV might serve as a potential entry point into a system for chronic care. Many patients

with TB and/or HIV patients do not adhere to treatment due to the challenges they face. The same holds true for other diseases (Figure 5-6). When looking at compliance with a variety of oral treatments over time, there is a similar trend: people take their medications for the first month, but drop off by the third month and continue to decline. These demonstrable adherence problems, even among people with non-communicable diseases, have huge health system repercussions. However, adherence problems might be solved by creating a system for delivery.

Figure 5-6. Compliance with oral medications


Healthcare delivery knowledge is a key gap in the current approach to health delivery, argued Keshavjee. We have good basic science knowledge (pathophysiology), relatively good clinical science knowledge (diagnosis and

appropriate intervention), and at times, good evaluation of the intervention and delivery model works. “But what we don’t know,” he said, “is how to actually deliver care. That’s where the health system can learn from TB.”

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Building this platform for community-based care delivery for TB and DR-TB is a first step in creating a platform for community-based care delivery for chronic disease, he said. Instead of dismantling TB systems, as some countries have done, he envisioned transitioning such those systems into 21st century platforms for community-based care delivery for chronic disease, thereby extending the reach of the clinic into the communities where patients live. The platform could be used for treatment of chronic conditions such as hepatitis C, diabetes, lung disease, heart disease, mental health disorders, and so on.

Keshavjee used the example of diabetes to illustrate the cost of inaction. Diabetes affects 450 million people worldwide as of 2015; by 2030 this will have risen to 700 million. Around 80% of people with diabetes live in low- and middle-income countries and around 225 million people (50%) with diabetes are undiagnosed. Diabetes can cause retinopathy, sores due to peripheral vascular disease, and limb amputation: all of these consequences are preventable. Diabetes caused more than 5 million deaths in 2015, he said, and it caused at least USD 500 billion dollars in healthcare expenditures in 2015, including 12% of total healthcare expenditures in adults aged 20-79 years. The cost of inaction is extremely high, as diabetes and its sequelae (i.e., renal dialysis) risk overwhelming health systems. However, investing just a little bit more in ensuring that patients adhere, emphasized Keshavjee, translates into a huge benefit in cure because of the decrease in the cost per cured patient—because the person no longer has these problems. He called for using the TB system as an entry point for delivering care across a spectrum for chronic diseases, from light care (such as SMS, phone calls, and internet portals) all the way to heavy care, such as nurse home visits.

5.3 PANEL 4 DISCUSSIONFarmer noted that the PACT model actually arose out of TB care: lessons learned from TB were directly imported and then applied to HIV and to major mental illness. He said that the risk

factors described by Gelmanova for Russia are identical to the ones seen in the U.S., such as comorbidities or being in and out of prison. They are not the same you might see in rural Ethiopia, however.

Pietroni reflected on a “lightbulb” moment he had experienced two years prior. At a writing retreat, another attendee was the secretary of state for the department of transport in the U.K. He pointed out that the problems of health systems are similar to a transport issue: you have many stations (clinics, doctors, patients, pharmacies, etc.) with no rails connecting them and no timetable. It is as if a patient is given a ticket to a destination, but there is no connecting rail service available. To address this in the U.K., they have put “care coordinators” in place to plan the patient’s journey, like how a travel agent puts together an itinerary. Unpaid volunteer “expert patients,” who are people who have already navigated the system themselves, act as these care coordinators. As a young doctor, Pietroni trained under Cicely Saunders, who opened the first hospice in the U.K., and she told him that in this hospice, “feelings are facts.” The key to palliative care is this recognition of the need to validate the patient’s feelings, he remarked.

Komarov noted that in the Netherlands, the idea of euthanasia is not limited only to terminally ill patients. Anyone can decide if they want to die, regardless of whether they have a disease. He cautioned that sick people may not be the right people to decide that they should live or die. He noted that AIDS can now be treated and is no longer necessarily fatal: “Should we have allowed people with AIDS to kill themselves? TB is now curable, but should euthanasia have been an option when it was not curable?” In the case of cancer, treatment rates in the U.S. are at about 90%, he said, but the rate in Russia is only 53% because cancers tend to be diagnosed at a later stage. It is an issue of screening, he said, but above all, it is about acknowledging human rights.

On the topic of palliative care, Gelmanova shared the experience of her mother, who had


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cancer and was convinced not to continue treatment because it would require several days of inpatient care in Krasnoyarsk, versus the matter of hours it would take in an outpatient setting in Moscow. It was very difficult to access her mother’s right to palliative care, she said. Only one specialist in Siberia could recommend the appropriate treatment, but only a different doctor from another part of the system could write the prescription for morphine. Doctors were highly reluctant to provide palliative care to her mother due to the putative risk of addiction. Eventually, Gelmanova had to administer most of the palliative treatment herself and she was only able to do so because of connections, money, and knowledge. Doctors were indignant with her and threatened to report her to the police for using too much morphine. “I can’t understand how people sitting in their homes without any help or assistance can access palliative care. What we do for TB, patients with cancer can only dream about.”

Farmer noted that this experience underscores the importance of having multiple care delivery agencies, as they do in Canada and the Netherlands. In affluent, developed nations across the world, he said, there is enormous fractionation and verticalization of systems, rather than integration. In TB control, he noted, there are models of care that can connect to the primary-care system and to people’s homes despite being vertical programs.

Sergei Borisov of the U.S. Embassy reflected on the significance and impact of Farmer’s 1998 article for Russian TB specialists.42 There was ongoing debate at the time about whether every district therapist (uchastkovy) would have only five or six TB patients in his uchastok to manage. One of the arguments against this was Farmer’s article. The community of TB doctors managed to introduce a system whereby those TB doctors and facilities would not only work with TB patients, but would also work to help prevent the spread of TB infection among healthy people in the population at large. This is

42 Farmer P, Kim JY. Community based approaches to the control of multidrug resistant tuberculosis: introducing “DOTS-plus.” British Medical Journal 1998;317(7159):671-674.43 Komarov noted that there is pervasive “oncophobia” in Russia that must be addressed, however.

one of the advantages of the TB community he represents.

According to Borisov, “We should deal with people not only when they are ill with TB, we should prevent the spread of the disease.” This should also apply to oncology,43 diabetes, and other conditions. He questioned whether it is feasible and realistic to place demands upon district therapists to work with the healthy population in addition to the dozens of programs they already have on their shoulders. Programs should be in place both for healthy patients and for high-risk groups, he argued, but implementing such programs can only be done in facilities such as TB facilities. There are procedures and processes in place for providing healthcare to patients and if doctors fail to comply, an oversight agency will penalize them. He explained that this creates a situation where people enter the system only to be treated when they are ill, but the critically important health promotion programs for the rest of the community are outside of that system (e.g., mental health). He suggested that the experience of the TB community could be emulated because TB control is similar to that for chronic diseases in the ambulatory care model. But success takes time, he warned. In Russia, it took ten years of continuous investment coupled with political will and support at all levels to gain evidence-based results that could not be refuted or challenged.

Borisov agreed with Keshavjee that TB facilities providing delivery in major cities like London, willingly or unwillingly, become social filters that retain pathologies with social determinants. It would not make sense to eliminate those facilities if TB is eliminated, because the principles and lessons these institutions have accumulated should be applied for other illnesses, such as diabetes. He noted that a TB institute in Russia that was founded prior to the antibiotic era was renamed as an institute of social pathology, and then ultimately renamed again for TB when it resurged.

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Farmer cautioned that a similar mistake was made in the United States in the 1970s, when federal funding for TB laboratories and chest clinics was eliminated. As a result, TB returned a decade later. Studies in Russia, South Africa, and the U.S. in which the patients’ blood levels were tested for the presence of anti-TB drugs have demonstrated that people simply do not adhere to treatment without support. Even with breast cancer patients and other pathologies, rates of adherence decline substantially over time. This applies to all pathologies that require adherence to difficult regimens, he noted.

For example, one study of treatment adherence among people diagnosed with seizure disorder found that none of the patients had supra-therapeutic (i.e., toxic) blood levels, most people did not have therapeutic levels, and one-third of the patients had no detectable levels of

anti-seizure medication in their blood at all. Arguments about reform are often tantamount to just cutting services, he warned: “If reform can mean cutting service or improving it—that is, making it more effective or erasing it—then how useful the term is at all is an open question.”

Farmer closed the meeting by thanking the hosts and organizers, and was hopeful that the proceedings would constitute an ongoing discussion that is quite different than the internal conversations ongoing in the TB community, which are very focused on specific therapeutics, diagnostics, and infection control. “We are engaged in this struggle to promote health and wellbeing, very broadly conceived, especially from those who have been somehow shut out of material modernity.”


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