The Program of dispensarization in Russia has raised the priority of the population-based preventive activities. The early identification of illnesses is currently viewed as one of the major areas of health policy. Primary care providers are increasingly focused on delivering check-ups and screenings to identify new cases and this work is financially encouraged by the government. There is a substantial progress of the coverage of the population and the number of identified illnesses. However, the expectation that the Program will substantially improve the results of medical interventions and ensure health gains seems too high.
The empirical evidence indicates that two important components of the screening programs pathway – follow-up management of identified cases and monitoring – are poorly represented in the Program. More than half of DPs are unaware of the distribution of their patients across health groups, they don’t know the results of check-ups and screenings. The reported coverage and quality of the follow-up management of identified cases are low.
The revealed interaction of preventive and curative activities does not meet the prevailing conceptual approach based on the assumption that a screening program pathway should include a stage of the follow-up management of the detected illnesses: ‘…there is no point in offering a screening program if there are insufficient facilities or health personnel to provide treatment for those who need it’ . The authors give an example of a mass screening program for thyroid cancer in South Korea in 1999, which led to the number of cases being detected increasing 15-fold and yet no reduction in mortality from thyroid cancer. In Russia, the Program is focused on the identification of new illnesses. This creates the risks of violating the principle of a continuum of preventive and curative activities. The Program might be less ambitious about the identification of new illnesses but focused on risk groups and include the management of new chronic cases.
Another issue of the Program design and implementation is a gap between its major objective and the capacity of primary care. The gap with resources leaves physicians of polyclinics with two major options. The first is to substitute a usual curative work for check-ups and screenings, which is not easy because of the influx of new cases. The second is to report optimistically about the progress of the Program implementation with an upward distortion of its coverage and to underprovide the follow-up care of the detected cases. The survey indicates that physicians agree with a common opinion that the actual coverage of the Program is much lower than the one reported by health authorities.
The Program uses some specific instruments unknown or uncommon internationally. First, its implementation in urban areas is based on the model of a big multi-specialty polyclinic. The major strength of this model is its capacity to provide comprehensive preventive and curative care. Patients can undergo check-ups and screenings, see DPs and specialists ‘under one roof”. Also, a polyclinic model is expected to demonstrate the additional leverage to implement integrated care pathways. But to make this happen, specific integrative and managerial activities are needed. There is some evidence that this strength is not fully realized in curative work . Our survey provides the evidence of a poor interaction of physicians in the dispensarization process. More than a half of DPs don’t report coordination with specialists.
Another specific instrument is the establishment of preventive units in polyclinics, that have taken on some traditional preventive functions of DPs. This innovation may strengthen the capacity of polyclinics to implement the Program under the condition that professions of preventive units coordinate their work with DPs. Our survey indicates their inadequate interaction with the risk of the violation of the unity of preventive and curative work. Thus, the potential of a preventive unit is not fully used.
Forming population health groups according to the results of the medical examination is also a useful instrument of the Program. It can be used for resource planning. The share of the third group with the lowest health status increased from 44% in 2013 to 54% in 2018 .
An important instrument of the Program implementation is its support and large-scale promotion by the Government. The opportunities and benefits of preventive activities are widely presented in the state media and official websites with the focus on the information how and where to pass medical examination. Private employers are legally required to promote the involvement of their employees and to offer them a day-off once a year to undergo the dispensarization . In some regions, temporal offices for check-ups have been established in popular trade and recreation zones (for example, there were 46 such offices in Moscow city parks in 2019 ), as well as in big educational institutions and industrial centers. In addition to the support activities, administrative pressure is used wherever possible. Public servants, teachers, medical workers, students and some other groups of population are strongly recommended to participate in the campaign. There are voices to introduce financial sanctions for those who ignore the Program, including increasing their contribution to mandatory health insurance. All these strategies contribute to the Program coverage. However, physicians tend to think that the population is rather passive in spite of a large-scale promotion of the Program by the government.
A specific instrument is a ‘finished case of preventive care’ as a provider payment unit, which is designed to motivate providers to offer check-ups and screenings. It really works. The number of preventive check-ups of adults increased by 2.1 times over 2012–2018, children – by 25% . The opposite side of the coin is that this instrument limits the professional autonomy of physicians on the choice of preventive services for an individual. They have to provide the entire bundle of services to be reimbursed, irrespective of the actual need of a patient. Inversely, a necessary test that is not included in the list of the ‘finished case’ will not be paid. Internationally, fee-for-service, pay for performance and program-based payment are used to promote preventive activities in addition to a capitation method. FFS is used to promote only priority preventive services, while the latter two methods stimulate reaching specified targets – the coverage of a certain population group, a regular work with chronic and multiple cases, decrease in hospital admissions and other targets that reflect an integrated preventive and curative work rather than a delivery of a fixed set of services to identify new illnesses [27, 28].
The role of a highly centralized administration of the Program is controversial. On the one hand, the federal government has initiated it, provided regions with additional funding, made the campaign a priority of health policy. The centralized leverage is needed to involve providers in preventive activities and to control their actual implementation, as well as to promote participation of people in check-ups and screenings.
On the other hand, a highly centralized pattern of the Program design and implementation has a number of drawbacks. Uniform target population groups and a set of preventive activities limit the flexibility of regions in responding to local needs and special conditions – variation in the disease incidence, the capacity of PHC, the most vulnerable population groups. Centrally established indicators of the population coverage, volumes of preventive care and the number of identified illnesses make regional health authorities and PHC providers look for the ways to reach the targets irrespective of the local capacity to treat new cases. The professional autonomy of physicians to select their own patterns of preventive work is limited by a chain of vertically determined rules.
Reporting and monitoring of the Program outcomes follows the logic of the centralized administration and politically loaded campaigns. The federal MoH makes an emphasis on easily attainable indicators and targets so that to ensure and to show the progress. The actual health gains due to the dispensarization are beyond the scope of monitoring. To the best of our knowledge, there are no attempts to assess: a) the impact of specific tests and screenings on the identification of new cases, b) the actual coverage, specific activities and health outcomes of the follow-up dispensary surveillance, c) the cost of specific preventive services, d) the cost effectiveness of the entire Program and its elements. This is a serious limitation for the Program adjustment to the activities with the highest health gains and cost effectiveness. A virtual absence of a sound measurement and monitoring can hardly be attributed to the lack of qualification. Rather, it is a by-product of a command-and-control governance of the health system.