Implementing general practice in Russia: getting beyond the first steps.

Over the past 15 years the countries of central and eastern Europe have been discarding the Soviet system of health care. A key element of many of the reforms is the replacement of the old model, based on narrow specialties located in policlinics, with one of integrated primary care, centred on general practitioners (GPs). Despite a formal commitment to primary care, in reality this sector had been starved of resources. It delivered poor quality care and had a low threshold for referral to hospital. Development of a new model of general practice began in Russia the 1980s, with pilot projects in St Petersburg, Kemerovo, and Samara; in 1992 the Russian Ministry of Health enacted the legislation that provided the basis for reform. 9 A new training curriculum was developed at the federal level, while allowing regional variations; training centres were established, often with help from international donors. The first cohort of GPs was trained in 1992. The adoption of a model based on general practice sought to strengthen primary care while tackling excessive specialisation, 10 although other factors were also at work. There was a political imperative to converge with western European models, of which that in the United Kingdom was among the best known. Western donors were also influential, arguing that radical change would be easier than reforming the entrenched policlinic model. However, critics have argued that the transformation of specialists into generalists has been problematic and demotivating, requiring a major investment in training and institutional change. Others have observed how newly trained staff have often become isolated, leading to two often disconnected models of care, with fundamental structural problems being ignored. This has led some commentators to argue that it would have been preferable to reorganise the policlinics (retraining district physicians and creating incentives for them to retain patients), engage in health promotion, and integrate primary and secondary care. On the other hand, family practice has been implemented successfully in some places where there has been a coherent reform framework, with institutional support and consistent incentives. 14 Which model is best remains a subject of debate, although the general practice model has been universally implemented, with little testing of alternatives. Despite the scale of the reform taking place, and the large investment involved, little information is available on how the new model is working. We describe here the implementation of general practice in Russia.We explore the views of the directors of all 15 general practice training centres that are currently operational in Russia, acquired through a questionnaire survey in 2002 and through subsequent interviews that explored some issues in more detail.