primary health care assignment

• Systematic review
• Open access
• Published: 30 September 2016

Access to primary health care services for Indigenous peoples: A framework synthesis

• Carol Davy   ORCID: orcid.org/0000-0002-8564-159X 1 ,
• Stephen Harfield 1 ,
• Alexa McArthur 2 ,
• Zachary Munn 2 &
• Alex Brown 1  

International Journal for Equity in Health volume  15 , Article number:  163 ( 2016 ) Cite this article

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Indigenous peoples often find it difficult to access appropriate mainstream primary health care services. Securing access to primary health care services requires more than just services that are situated within easy reach. Ensuring the accessibility of health care for Indigenous peoples who are often faced with a vast array of additional barriers including experiences of discrimination and racism, can be complex. This framework synthesis aimed to identify issues that hindered Indigenous peoples from accessing primary health care and then explore how, if at all, these were addressed by Indigenous health care services.

To be included in this framework synthesis papers must have presented findings focused on access to (factors relating to Indigenous peoples, their families and their communities) or accessibility of Indigenous primary health care services. Findings were imported into NVivo and a framework analysis undertaken whereby findings were coded to and then thematically analysed using Levesque and colleague’s accessibility framework.

Issues relating to the cultural and social determinants of health such as unemployment and low levels of education influenced whether Indigenous patients, their families and communities were able to access health care. Indigenous health care services addressed these issues in a number of ways including the provision of transport to and from appointments, a reduction in health care costs for people on low incomes and close consultation with, if not the direct involvement of, community members in identifying and then addressing health care needs.

Conclusions

Indigenous health care services appear to be best placed to overcome both the social and cultural determinants of health which hamper Indigenous peoples from accessing health care. Findings of this synthesis also suggest that Levesque and colleague’s accessibility framework should be broadened to include factors related to the health care system such as funding.

Ensuring access to primary health care is widely accepted as key to improving health outcomes [ 1 ]. In the case of Indigenous populations living with high rates of chronic disease, access to these services is even more crucial [ 2 ]. Even in developed countries such as Australia, the number of Indigenous peoples dying from cardiovascular disease is 1.5 times that of their non-Indigenous counterparts [ 3 ]. Despite this, Indigenous peoples are often prevented from accessing these types of services due to a range of barriers including the high cost of health care, experiences of discrimination and racism and poor communication with health care professionals [ 4 ]. Evidence suggests that access to primary health care can be improved when services are tailored to the needs of, or owned and managed by Indigenous communities themselves [ 5 , 6 ]. This is because Indigenous health care services are more likely to be free of racism and are generally more culturally appropriate than mainstream services [ 7 ]. They also tend to employ Indigenous staff who are able to speak the local language and are often known by people accessing the service [ 8 ].

Accessing primary health care is therefore far more complex than simply locating a service within or close to Indigenous communities [ 9 ]. Nevertheless, measures of access at a population level are often confined to spatial factors including location and distance, using primarily quantitative data. In Australia, for example, a rural index of access combines system measures such as the number of health services within a given area and the population-provider ratio, with measures including the type and degree of identified health needs, distance to the nearest service and a mobility score [ 10 ]. Others have used less complex scores focusing on distance [ 11 ], travel time [ 12 ] and supply and demand ratios [ 13 ]. Quantitative measures of socioeconomic status with indicators of disadvantage have also been included [ 14 , 15 ]. Clearly these quantitative perspectives ignore many of the access issues relevant to Indigenous peoples such as the ability of the service to accommodate the social and cultural needs of Indigenous peoples, the provision of health care by Indigenous staff in an Indigenous friendly space and considering the important role that communities and families often play within the care process [ 16 ].

Problems associated with defining access have contributed to the complexity about what should be measured. Early research defined access in terms of how well available services are able to meet the health needs of the populations they serve [ 17 ], or alternatively how well patients are able to access health care given their particular capacity to seek and obtain care [ 18 , 19 ]. These types of definitions tend to place responsibility for access on either the health service or the potential user. Not all researchers agree with this dichotomy. For example Haggerty et al. [ 20 ] suggested that both provider and patient factors are important, suggesting that the term ‘access’ best refers to the ability of the population to obtain appropriate health care services, while ‘accessibility’ best refers to the ability of the health care service or system to respond to those needs. Other frameworks have exemplified the importance of the user/service interface [ 21 ] suggesting that access to health care is jointly negotiated between the patient and the health care service [ 22 ].

Levesque et al. [ 23 ] built upon this earlier research by developing a more holistic conceptual framework based around broader definitions of access to and accessibility of health care services. Both user and health care service characteristics are incorporated within the five stage linear framework. The strength of Levesque et al’s framework is that their model of access does not stop at the user reaching the health care service but instead considers important access issues in relation to Indigenous peoples engaging with and remaining engaged with care overtime [ 24 ]. Stage one, Perception of Needs and Desire for Health Care , is influenced by the ability of people to recognise a need to seek care (Ability to Perceive) and by the degree to which the health care service is known to exist (Approachability). Stage two, Health Care Seeking , focuses on the ability of people to freely seek out services when needed (Ability to Seek) and the appropriateness of health care services relating to, for example, the social and cultural norms that underpin the communities they serve (Acceptability). Stage three, Health Care Reaching , focuses on how easy it is for individuals to get to the service when needed (Ability to Reach) and whether health care services can be reached in a timely manner (Availability and Accommodation). Step four, Health Care Utilisation , encompasses the cost to patients accessing services (Ability to Pay) and the expenses incurred in running a health care service (Affordability). Stage five, Consequences of Accessing Health Care , considers how well the individual is able to engage with the care that is offered (Ability to Engage) and the extent to which the care provided meets the needs of the communities they serve (Appropriateness) (Fig.  1 ).

Levesque et al. [ 23 ] model of access to health care reprinted with permission

A recently completed scoping review [ 25 ] identified and described the characteristics (values, principles, components and suggested practical applications) of models of service delivery implemented within primary health care services that predominantly provide care for Indigenous people worldwide. One of the key characteristics which underpinned these models of service delivery was access. In particular, these initial findings suggested that community needed to be aware of the service and that services in turn need to ensure that they provided affordable, available and acceptable care. The primary objective of the framework synthesis presented in this paper was to systematically re-examine literature included within the previous scoping review in order to identify and better understand factors that influenced access to and accessibility of these Indigenous health services.

Our framework synthesis primarily aimed to identify the challenges faced by Indigenous peoples attempting to access care and then explore how Indigenous health care services addressed those challenges using the more holistic framework developed by Levesque et al. [ 23 ]. Identifying both the challenges and the ways in which they have been addressed will assist mainstream services to improve the accessibility of their health care. We also sought to explore whether the framework developed by Levesque and colleagues was useful for exploring access to and the accessibility of Indigenous health care services in particular. To our knowledge this is the first synthesis to look at the issues of both access and accessibility of Indigenous health care services using Levesque et al’s framework.

The focus and design of the original scoping review and this framework synthesis were guided by a Leadership Group comprising 24 senior members of the Aboriginal Community Controlled Health Sector. The original scoping review research team, led by an Aboriginal Research Fellow was also involved in this new framework synthesis. While all of the authors were experienced in synthesising data, we believe our findings were strengthened by the involvement of Indigenous researchers who guided the interpretation of data.

The original scoping review

The original scoping review summarised below aimed to identify the characteristics (values, principles and components) of Indigenous primary health care service delivery models. Further information on the methods used and the design for the scoping review can be found in the published protocol [ 25 ].

Concepts of interests included characteristics (values, principles, components and suggested practical applications) of models of service delivery implemented within an Indigenous primary health service. Within the literature a number of different terms such as service delivery models of care and service frameworks have been used interchangeably to articulate the way in which services are or should be operationalised.

Service delivery models implemented within settings where primary health care services were provided predominantly for Indigenous peoples were included in the original scoping review. Indigenous peoples were defined as:

“Indigenous populations are communities that live within, or are attached to, geographically distinct traditional habitats or ancestral territories, and who identify themselves as being part of a distinct cultural group, descended from groups present in the area before modern states were created and current borders defined. They generally maintain cultural and social identities, and social, economic, cultural and political institutions, separate from the mainstream or dominant society or culture.” ([ 26 ], para. 1)

Primary health was defined as:

“…socially appropriate, universally accessible, scientifically sound first level care provided by health services and systems with a suitably trained workforce comprised of multi-disciplinary teams supported by integrated referral systems in a way that: gives priority to those most in need and addresses health inequalities; maximises community and individual self-reliance, participation and control; and involves collaboration and partnership with other sectors to promote public health. Comprehensive primary health care includes health promotion, illness prevention, treatment and care of the sick, community development, and advocacy and rehabilitation.” ([ 27 ], para. 3)

Types of sources

All qualitative, quantitative, economic and mixed methods studies were considered for inclusion in the original scoping review. In addition reviews and systematic literature reviews of programs that meet the inclusion criteria were also retrieved. Only literature published in English from September 1978 were considered in the original scoping review as this is the date that the Declaration of Alma Ata which outlined primary health care was adopted at the International Conference on Primary Health Care. [ 28 ]

Search terms

Initial search terms used in the original scoping review included Aboriginal, Aborigine, Indigenous, first nation, Maori, Inuit, American Indian, primary health care, comprehensive primary health care, medical service, health service, community care, community health care, model.

Search strategy

A three-step search strategy was utilized in the original scoping review. An initial limited search of PubMed and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. Second, a search using all identified keywords and index terms was then undertaken across EBSCO, CINAHL, Embase, Informit, Mednar and Trove. Third, the reference list of all identified reports and articles was searched for additional studies. In addition, academics from universities with expertise in Indigenous health services were contacted and asked to identify literature (particularly grey literature) that meets the review inclusion criteria.

Articles were assessed for inclusion in the initial scoping review by title and abstract. Full text of the articles were retrieved if they meet the inclusion criteria or if further examination was required. Two reviewers independently confirmed that the full text article meet the inclusion criteria. Any disagreements was decided by a third reviewer.

This framework synthesis

To be considered for this new framework synthesis, papers must have been included in the previous scoping review and present findings related to one or more of the five stages included in Levesque et al. [ 23 ] framework (Fig.  1 ). Findings from these papers were firstly extracted and then imported into NVivo 10. A framework synthesis [ 29 ] was used to aid in the analyse and the interpretation of the extracted findings. This entailed identifying a priori framework, in this case the five stages offered by Levesque et al’s framework [ 23 ] and then charting and sorting the findings from the included papers into the five stages identified by Levesque and colleagues framework (Table  1 ).

Of the 62 papers included in the original scoping review, 50 met the inclusion criteria for this framework synthesis [see Additional file 1 : Table S1]. Twenty four of these papers reported on Indigenous Health Care Services based in Australia, 15 within the United States, four in Canada and New Zealand, two in South America and one in Papua New Guinea. The majority of the papers ( n  = 30) included in this synthesis reported on a range of primary health care services. A small number of included papers reported on services which were specifically designed to address maternal and child health ( n  = 5), mental health ( n  = 4), chronic disease management ( n  = 3), oral health ( n  = 3), eye health ( n  = 1) cancer treatment ( n  = 1) and women’s health ( n  = 1). Findings from the synthesis of evidence identified a number of factors related to all five stages of Levesque et al’s framework [ 23 ] (Table  2 ).

Levesque et al’s [ 23 ] accessibility framework was a relatively useful tool for identifying the range of issues which influence access to as well as the ways in which Indigenous health care services address these issues. However, findings suggest two additional improvements, at least in relation to access to health care services for Indigenous peoples. First, the broader health care system rather than a particular service or the user also appeared to influence access to and acceptability of care. Funding was the most obvious system issue identified by this framework synthesis. As indicated in Table  2 above, Indigenous health care services operated within constrained budgets resulting in a reduction of services for Indigenous peoples.

Our second finding relates to the linearity of Levesque et al’s framework [ 23 ] which, in the case of Indigenous health care services did not accurately portray relationships between features of access and accessibility. For example, we found a closer relationship between the ability to pay and the ability to reach than was suggested by the original linear framework. For example, studies demonstrated that the cost of transport to the health care service was as prohibitive as the cost of health care. We also found that the ability to engage was as relevant to health care acceptability as it was to appropriateness. A non-linear representation which provides space for factors relating to health care system systems more broadly (Fig.  2 ) may better illustrates the many inter-related features that influence access to and acceptability of health care services.

Accessibility Framework for Indigenous peoples accessing Indigenous primary health care services

The primary aim of this framework synthesis was to explore access to (factors related to Indigenous patients, their families and communities) and accessibility of (factors relating to services) Indigenous health care services using the Levesque et al. [ 23 ] framework. We found issues relating to both the social and cultural determinants of health hampered Indigenous patients’, their families’ and communities’ from accessing care. Poverty was a prominent social determinant of health issue with some Indigenous peoples finding it difficult to afford either transportation to, or the costs of, obtaining services. This review also found that a lack of basic communication infrastructure within communities such as telephones prevented access to health care guidance and advice. To overcome these issues some Indigenous health care services provided transport to and from their facility, or alternatively provided outreach services which delivered care into the patient’s home. Despite limited funding, Indigenous health care services also subsidised these costs for Indigenous peoples on low incomes. While this review highlighted poverty and the lack of communication infrastructure, other related social determinant of health issues such as unemployment and lower levels of education also impact on an Indigenous persons’ ability to access health care services [ 30 ]. Health care services that are both cognisant of and able to address the social determinants of health relevance within their particular context will be crucial for improving access to health care services for Indigenous communities.

The types of cultural determinants of health that influenced Indigenous peoples’ ability to access health care related to the ability of the health care service to understand and take account of local beliefs and values when providing care. In this framework synthesis we found that community acceptance was key to both seeking and engaging with health care services. The acceptability of services depends on health care providers understanding the cultural, historical and social fabric of the communities they serve [ 31 ]. However, simply understanding is not sufficient. Instead a deeper level of interaction and thoughtful practice that ensures culturally safe services, as defined by those who receive services, is required [ 32 ]. To support this view, we found that Indigenous health care staff, particularly those from local communities, were associated with increased Indigenous health care engagement. Indigenous health care services included in this review also actively sought to engage with and learn from local Indigenous peoples. In some instances Indigenous health care services were owned and managed by local Indigenous peoples resulting in a sense of community ownership and promoting the use of culturally safe models of health care.

Indigenous health care services may therefore provide the best opportunity to address access because they are in a better position to address the types of social and cultural determinants of health faced by Indigenous communities. They are, for example, generally situated within or at least near to the communities they serve and are more likely to be aware of local values, norms as well as health care needs. Indigenous health care services are also more willing to work with communities in order to respond to local needs. Importantly, Indigenous services owned and managed by Indigenous peoples are more likely to develop culturally safe models of care [ 33 ]. In contrast, mainstream services are generally set up to cater for dominant often non-Indigenous cultures and may not have the resources required to respond to the needs of others. Mainstream services also tend to operate within a set of socially constructed values and norms which can at times, be at odds with Indigenous communities’ beliefs and values – the delivery of mainstream services being predominantly influenced by the biomedical model rather than a more holistic sense of health adopted by many Indigenous peoples [ 34 ].

Finally, we suggest two changes to Levesque and colleagues’ framework when evaluating Indigenous peoples’ access to and the accessibility of Indigenous health care services. The first relates to the inclusion of the health care system as part of the framework. Health policies and practices at a systems level have a profound effect on the ability of Indigenous peoples to access health care [ 35 ]. While funding was the health care system issue identified in this review, national policies in relation to, for example, the provision of outreach services will also be crucial for improving health outcomes for Indigenous peoples [ 36 ]. The second change emanating from this framework synthesis relates to a move from a linear perspective of access and accessibility to one that better represents the inter-connectedness of all of the identified features. Journeys into and through health care services for Indigenous peoples, particularly in relation to those living with chronic illness, are anything but linear. There are often no clearly defined entry or exit points. Instead, an Indigenous patient journey will depend on the individual, their family and geographical context [ 37 ]. Common factors for successful navigation include, however, the importance of culturally safe and wherever possible, locally owned Indigenous health care services that are able to understand and meet the needs of the communities they serve [ 38 ]

Limitations

While there were a large number of included papers in this framework synthesis, we acknowledge that this does not capture all of the issues related to access to or accessibility of Indigenous health care services for four reasons. First, no matter how systematic, there is always a possibility that the original scoping review [ 25 ] did not identify all potential papers. Second, the aim of the original scoping review was to identify and describe Indigenous service delivery models rather than necessarily Indigenous peoples’ views on access to health care more generally. While access and accessibility were common themes emerging from the scoping review it is likely that other studies focusing on the accessibility of Indigenous health care services could have informed the specific objectives of this synthesis but did not meet the scoping review’s inclusion criteria. Third, while the papers included identified important social and cultural determinants of health issues relating to access, we believe that further research is required in order to increase our understanding of these issues. Finally, we acknowledge a need to further explore factors relating to the health care system which facilitate as well as those that impede access to and the accessibility of Indigenous health care services.

The framework synthesis outlined in this paper makes a number of contributions to the body of knowledge around access to and accessibility of health care services. In particular, we demonstrate how social and cultural determinants of health influence the extent to which Indigenous peoples are able to access health care services. Importantly, we also describe ways in which Indigenous health care services are addressing these issues and why they are best placed to do so. Based on outcomes from this framework synthesis, we have proposed further additions to Levesque et al’s [ 23 ] accessibility framework including the inclusion of systems issues including those relating to the funding of Indigenous health care services, which appear to influence access to and acceptability of health care services.

Abbreviations

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Acknowledgements

This paper is part of work supported by National Health and Medical Research Council (NHMRC) Grant No 1061242. The published material is solely the responsibility of the individual authors and do not reflect the views of NHMRC.

The authors in this paper were supported by National Health and Medical Research Council (NHMRC) Grant No 1061242.

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CD collaborated in the design of the original scoping review, analysis of the findings for this synthesis and was primary author. SH collaborated in the design of the original scoping review, analysis of the findings for this synthesis and reviewed the paper. AM and ZM assisted with the original scoping review, contributed to the findings of this synthesis and review the paper. AB collaborated in the design of the original scoping review, analysis of the findings for this synthesis and review this paper. All authors read and approved the final manuscript.

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Davy, C., Harfield, S., McArthur, A. et al. Access to primary health care services for Indigenous peoples: A framework synthesis. Int J Equity Health 15 , 163 (2016). https://doi.org/10.1186/s12939-016-0450-5

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Primary Health Care

PHC, or primary health care, is “essential health care” that is based on scientifically sound and socially acceptable procedures and technology. This ensures that all individuals and families in a community have access to universal health care. PHC programs enable community members to fully participate in implementation and decision making. In the spirit of self-reliance and self-determination, services are supplied at a cost that the community and the country can afford at each stage of development.

Primary healthcare refers to the initial point of contact a person has with the health system when they have a non-emergency health condition or issue. It is the most commonly used component of the health-care system and may be supplied by a general practitioner (GP), physiotherapist, or pharmacist, among others. It is delivered in a community environment, such as a general practice or dental clinic. Primary healthcare practitioners may work in medical clinics, community health centers, and allied health services such as physiotherapy and podiatry.

In other words, PHC is a health approach that goes beyond the standard health care system and focuses on health equity-producing social policy. PHC encompasses all aspects of health, such as access to health services, the environment, and lifestyle. Thus, primary healthcare and public health initiatives can be viewed as the foundations of universal health systems.

Within their area of specialization, a basic healthcare service may diagnose and treat common health disorders. They can also assess the seriousness of your medical concerns and point you in the right direction for treatment. They may also be able to refer you to other medical professionals if necessary. PHC addresses not only individual and family health requirements, but also the broader issue of public health and the needs of designated populations, by delivering care in the community as well as care via the community.

The World Health Organization, or WHO, elaborates on the goals of PHC as described by three broad categories: “empowering individuals and communities, multisectoral policy and action; and primary care and vital public health functions as the basis of integrated health services.” Based on these definitions, PHC can not only assist an individual who has been diagnosed with a sickness or disorder, but can also actively avoid such disorders by comprehending the individual as a whole.

Since 1978, the idea of PHC has been continuously reinterpreted and modified, creating misunderstanding about the word and its application. PHC is founded on a dedication to social justice, equity, solidarity, and participation. It is based on the recognition that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction.

This ideal model of healthcare was accepted in the statement of the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (known as the “Alma Ata Declaration”), and became a basic notion of the World Health Organization’s goal of Health for All.

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[The results and perspectives of primary health care reforming in Moscow]

Affiliations.

• 1 N. A. Semashko National Research Institute of Public Health, 105064, Moscow, Russia, [email protected].
• 2 N. A. Semashko National Research Institute of Public Health, 105064, Moscow, Russia.
• 3 The Federal State Autonomous Educational Institution of Higher Education "The I. M. Sechenov First Moscow State Medical University" (Sechenov University) of Minzdrav of Russia, 119991, Moscow, Russia.
• 4 The Federal State Autonomous Educational Institution of Higher Education "The Peoples' Friendship University of Russia" (RUDN University) of Minobrnauki of Russia, 117198, Moscow, Russia.
• PMID: 35439388
• DOI: 10.32687/0869-866X-2022-30-2-270-274

The primary health care is characterized by its directivity to population health, while general practitioner is key figure in its organization and is responsible for assigned population health. The Russian Federation continues to suffer from overspecialization of medical care in outpatient health care. At that, the number of unreasonable visits to medical specialists is too high. The general practitioner, with appropriate training, can appoint patients by 11 specialties and in conditions of municipal polyclinic can undertake up to 81% of visits to medical specialists. The purpose of the study is to evaluate primary health care functioning in Moscow and to formulate proposals for reforming health care, considering development of general medical practices in a metropolis. The study was focused on analysis of morbidity of population of Moscow, on support of out-patient health care with physicians before and after implementation of three-level system of ambulatory polyclinic care, on evaluation of preventive activities of general practitioners and on development of proposals for improving organizational forms of activities with emphasis on health preservation. In the study were applied such methods as statistical, direct observation, sociological. The analysis was applied to forms of federal statistical observation i.e. form № 30 in Moscow and the Russian Federation for 2010-2019. The population sociological surveys concerning satisfaction with medical care were carried out. The research base was Moscow. The analysis demonstrated that results of Moscow health care system reformation is economically effective because of shortage of medical personnel primarily of administrative staff and its rational employment. The reformation results were positively assessed by patients, whose satisfaction with medical care made up to 95.6%. The general practitioner is to be responsible for health status of attached population and is called upon not only to carry out treatment and preventive activities, but also to coordinate organization of medical care of attached population at all stages of its provision. The implementation of general medical practice in conditions of municipality is to calculate complete transition of medical organizations providing out-patient medical care to general medical practice, that will result to certain extent, in reduction of staff positions of medical specialists. It is necessary to expand duties of medical nurse in general practice. The optimal model of joint work of general practitioner with feldsher and medical nurse of general practice. The complex general practice team can include medical registrar. The proposed perspective models permit to implement integrating role of general practitioner and to increase accessibility and efficiency of primary health care.

Keywords: general medical practice; general practitioner; medical organizations; medical specialists; out-patient medical care; primary health care; public health.

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Health workforce policy in the Russian Federation: How to overcome a shortage of physicians?

Russia looks for ways to overcome a shortage of physicians. Health workforce policy is focused on training an additional number of physicians. The current efforts have reduced some areas of the shortage but failed to solve the problem due to many factors that reproduce the deficit. A distorted structure of service delivery with weak primary care generates demand for outpatient specialists and hospital doctors and requires a perpetual increase in their number. The lack of long-term labor planning results in the oversupply of some specialties and the shortage of others. The regulation of post-graduate training is not enough to improve the allocation of physicians across specialties and health system sectors. We argue that an extensive increase in the number of physicians without changing their composition will hardly change the situation. A more active structural policy is required with a focus on strengthening primary care and improving planning and regulation of health workforce structure.

Introduction

The ability of health systems to respond to new challenges is heavily dependent on the deployment of an adequate supply of health professionals in sufficient numbers, operating in the right areas of service delivery, and with appropriate scope for professional development. This is particularly true for many post-Soviet countries that face inadequate health funding and the legacy of the “Semashko” model. Russia is among the world leaders in the physicians-population ratio: 4.2 physicians per 1,000 population vs. the average of 3.6 for OECD countries ( 1 ). However, the country now faces a serious problem of physician shortage, particularly in primary care. The Federal Ministry of Health (MoH) reports that around 20% of physicians' positions in polyclinics were unfilled in 2019 ( 2 ).

The coexistence of a relatively high number of physicians and their shortage is a phenomenon that can be accounted to many factors. Partly, this is the result of special health care needs due to country-specific factors such as harsh climate in many regions, low density of large rural population, and high incidence of cardiovascular diseases and accidents ( 3 ). The major causes for the Russian health worker supply imbalance, however, are evident in our former research ( 4 ) that indicates the important contribution of a deficit of primary healthcare physicians, unequal income opportunities for certain physician specialties, physicians are not adequately supported by nurses, and allied health personnel. The paradoxical situation of “too many too few” requires a special set of workforce policy interventions. Their analysis is relevant for countries that face similar problems.

Following the break-up of the Soviet Union in 1991, the Russian health system has undergone a significant transition to mandatory health insurance (MHI) but has retained its chronic underfunding. Public health expenditures have not exceeded 3.5% of GDP over the last decades ( 5 ). The institutional structure of service delivery has not changed much. Most of the facilities are state-owned. Primary health care (PHC) in urban areas is provided by multispecialty polyclinics—separate clinics for adults and children; each has a catchment area and a patient list managed by district therapists, district pediatricians, and general practitioners (GPs)—all of which are collectively referred to as ‘district physicians' (DPs). The catchment population of urban polyclinics ranges from 30,000 to 120,000 people. Big entities employ 15–20 categories of specialists. According to the legislation, PHC is practically the equivalent of outpatient care. Hospitals vary in size, the structure of specialties, and the number of patients ( 6 ).

To cope with the problem of physician shortage, the government has started a number of policy activities. The presidential decree of May 2012 set the task to increase the salary of physicians to the level of 200% of the average remuneration in the economy of the corresponding regions, and the salary of nurses to 100%. These targets have been reached in most of 85 regions of the country ( 7 ). But this important measure was not enough to eliminate the shortage. Additional measures have been taken, of which the most important is a national program “Providing medical organizations with qualified personnel” (further program) for 2018–2024 ( 2 ).

The objective of this paper is to explore the activities and outcomes of this program and some other policy activities. The major research questions: What are the major policy interventions? What are the factors driving the health labor imbalances? What should be done to solve this problem? We analyze the main developments over the last 10 years with a focus on the period of the program implementation.

The analysis is based on a review of the Russian and international literature, as well as materials of the federal and regional health authorities. The official statistical data are supplemented by our estimates and comparisons with OECD countries.

Policy options and implications

The program major activities.

The major objective of the program is to reduce the shortage of physicians and nurses with focus on primary care. While the government recognizes the existence of a critical imbalance in the health workforce, there is an inadequate study and debate on how best to improve the scope and impact of the program's interventions and investments.

The program is focused on increasing the number of physicians. The admission of students to medical universities increased from 2018/2019 to 2020/2021 by 20% in general medicine specialties [( 8 ), p. 117]. It is expected to raise the number of physicians in state medical organizations from 37.4 per 10,000 population in 2017 to 40.7 by 2024 ( Table 1 ).

Indicators and targets of the federal program “Providing medical organizations with qualified personnel” in Russia, 2017–2024.

Source: ( 2 ).

To achieve these indicators, a so-called “target enrollment” of students is expanding. It provides for the involvement of regional governments in the admission of students to medical universities, including post-graduate training. Regional policymakers are supposed to assess the demand for specific medical specialists in their regions, contract universities, and make commitments to financial subsidies for the education of students and the employment of graduates. The share of such targeted enrollments in the total number of admissions to medical universities is to increase from 57% in 2018 to 62% by 2024 ( 9 ).

Policies to facilitate health worker employment are being implemented with regional health employment centers established. These centers are to search for medical personnel in the labor market, attract physicians from other regions, and collect information on job vacancies for public distribution. The centers are also to promote the development of a so-called “shift method”, that is the employment of health workers for temporary work in local areas with an acute shortage of medical personnel ( 10 ).

To attract medical professionals, some financial benefits have been introduced, including a partial compensation of utilities. Since 2012, a special program has been implemented in rural areas and small towns. Physicians who choose the work in rural settings are provided with a lump sum to buy a house or an apartment.

To improve the quality of medical personnel qualifications, new professional standards and accreditation procedures are being introduced. They are to cover all medical workers in 2022. On contrary to this objective, the so-called “simplified accreditation” of medical university graduates was introduced in 2016. They are allowed to work as district therapists and pediatricians without passing post-graduate training—an approach unknown internationally ( 6 ).

Some outcomes indicators

These several policy interventions yield some important progress, but much more is to be accomplished. The number of physicians fell in 2010–2017 and then increased by 4.6% in 2018–2020. Physician–population ratio had the same trend. The increase in the last years was the result of additional enrollment of medical students. However, the supply of nurses had a downward tendency—both in absolute and relative terms ( Table 2 ).

Physicians and nurses in Russia, 2010–2020.

Source: [( 8 ), p. 114, 116].

To assess the shortage, the program established an indicator of staffing full-time positions of physicians and nurses. It is planned to increase the share of filled outpatient physician positions from 79.7% in 2017 to 95% by 2024. Nearly the same progress is planned for nurses ( Table 1 ).

Using this indicator, the MoH estimates a 39% decrease in the total shortage of physicians and a 37% decrease in the shortage of outpatient physicians over 2016–2019. The size of the latter in 2019 (before the start of the pandemic) was estimated at the level of 8.4%. Among the most wanted outpatient specialties are dentists, radiologists, orthopedic dentists, dermatologists, neurologists, surgeons, and ophthalmologists ( 2 ).

The declared strategy of PHC priority is not being realized. The total number of district physicians fell in the period 2010–2017 but then increased only by 1.1% in the period 2018–2021 ( Table 3 )—partly due to the influx of graduates from medical universities without post-graduate training. As a result, their capacity for high-quality health outcomes is constrained.

District physicians in Russia, 2010–2021.

Sources: Author's estimates based on ( 8 ).

The COVID-19 pandemic has aggravated the shortage of PHC physicians and limited their accessibility. The number of vacant doctor positions doubled in 2021 ( 11 ). According to a national population survey in October 2021, 70.1% of respondents reported “the inability to make an appointment with the doctor at first attempt” ( 12 ). The pandemic has revealed additional labor shortages, including the lack of infectious disease specialists, rehabilitators, nurses, and social workers. The qualification of many DPs was not enough to manage new cases. The government has mobilized hospital doctors. They took on the major burden of the pandemic.

In the hospital care sector, there is an oversupply of physicians. According to the official estimate, this surplus increased by 21% in the period 2016–2019. The oversupplied specialties include gynecologists, psychiatrists, surgeons, therapists, pediatricians, and radiologists. But at the same time, there is a deficit of hospital resuscitators, ophthalmologists, ultrasound specialists, and psychotherapists ( 10 ).

The special program for rural areas has started successfully. In 2012, 7,713 physicians and paramedics settled in rural areas as beneficiaries of the program. However, their influx has slowed down to the level of 5,338 physicians in 2018 ( 10 ). Financial benefits work relatively well but their funding is insufficient. The share of recipients of housing and utility allowances in the total number of physicians is only 5.8% ( 10 ). An additional limitation is the lack of rural physicians' professional communication with urban medical centers.

The results of the workforce policy, however, are highly dependent on the methodology of the shortage estimates. The official indicator of the occupied positions does not account for multiple job-holding by professionals. This is particularly true for primary care physicians. With a federal norm of 1,700 residents served by each district therapist, the actual average catchment area in 2019 was 2,690 residents, in some regions-−3,000–4,000 ( 13 ). According to the survey of physicians, 67% of Russian physicians occupy 1.5 or more positions ( 14 ). This phenomenon of multiple job-holding contributes to a substantial gap between the official estimates of the share of occupied positions and the estimates of the actual number of physicians. For example, in Karelia region, the former is 92.8% (nearly all positions are filled), while the latter is only 64.8% ( 15 ).

Our estimate of the actual shortage of district therapists, based on the norm of 1,700 adults per physician, is 32%, much higher than the official estimate ( 13 ).

While modest gains in reducing the supply shortages of certain types of physicians, the situation of ”too many too few“ has not changed much. The factors that create structural imbalances in the Russian health workforce are still in place.

Why is the physician shortage reproduced?

Service delivery disproportions.

They cause the imbalances in the health workforce in the following directions. First, primary care is still the weakest sector of the health system. The task profile of district therapists and pediatricians is limited, they manage only the easiest cases and refer nearly half of patients to outpatient specialists, while their European counterparts manage from 80 to 95% of cases without referrals to specialists ( 13 , 16 ). The institute of general practitioners with wide clinical and coordinating functions is poorly developed: the share of GPs in the total number of district physicians is only 12.8% and falling ( Table 3 ). This acts as the major driver generating demand for specialists. Meeting this demand is not easy; therefore, the shortage of some specialists is as acute as the deficit of generalists.

Second, a traditional hospital-centered model of service delivery remains in its major features. The number of bed-days per capita is still 70–75% higher than in the EU ( 6 ). The work in a hospital is very attractive for the graduates, and their annual influx has generated an oversupply of some hospital doctors. The MoH recognizes this oversupply, but the program does not provide for the redistribution of physicians to polyclinics: the share of outpatient care physicians in the total number of physicians in 2024 will be the same as in 2018, i.e., 55% ( Table 1 ).

Third, the level of physicians' specialization in Russia is very high: there are 92 specialties and subspecialties. Many routine diagnostic tests are performed by specific categories of specialists. Specialization of primary care has reached the point when specialists in polyclinics account for two-thirds of physician positions, while district physicians have lost their primary role. Specialists of polyclinics are usually not involved in inpatient care; therefore, the country needs two categories of specialists—for inpatient and outpatient care. For example, outpatient urologists do not do any surgery. This process of excessive specialization creates demand for an additional number of physicians and increases the number of unfilled positions.

Fourth, the physician shortage is reproduced by a deeply rooted division of labor between physicians and other medical personnel. The nurse-physician ratio in Russia is 2.3 to 1 and is not planned to increase by 2024 ( Table 1 ), while in the USA, Japan, and EU countries, 2.8–4.7 nurses to one physician ( 1 ). Nurses' clinical functions are traditionally low in Russia ( 6 ). No serious attempts have been made to reduce the demand for physicians by extending the functions of nurses.

Health labor planning patterns

Labor imbalances begin with a reliance on weak labor forecasting and planning systems at the regional and federal levels. A long-term vision of the structure of physicians' specialties is needed. In Western countries, in the early 2010s, there were long-term plans for the demand and supply of physicians and nurses in 2030 and even later. These plans were based on the assessment of epidemiological, socio-demographic, and technological factors ( 17 ). In Russia, such plans are unavailable. Post-graduate students' enrollment is based on the current assessment of the unfilled positions with a high probability of the graduates' supply not matching demand for specific specialties in the period of 8–10 years.

Regional target enrollment increases the responsibility of regional governments for the employment of graduates but does not reduce the probability of future disproportions across physician specialties. Contracting with medical universities is based on the estimate of current needs, rather than a strategic understanding of future demand and supply for the coming decades. Our analysis of the websites of several regional health authorities shows that not a single region posted estimates of the long-range need for personnel, broken down by individual medical specialties.

The federal MoH has developed a planning methodology, which is based on health care utilization and the number of physicians and nurses per unit of the volume of care ( 8 ). But this methodology also suffers from its focus only on current supply and distribution needs. Furthermore, the focus on utilization often provides distorted estimates. For example, a decreasing number of visits to PHC physicians per resident (the recent trend in Russia) results in a decreasing need for the number of primary care physicians. This is contrary to the current objective to strengthen primary care. Other supply factors not addressed include patterns in demographic, trends in disease incidence, and general labor conditions for housing, income, and lifestyle.

Inadequate regulation of physicians post-graduate training

The federal MoH develops quotas for the annual admission to post-graduate training in individual specialties, which are then distributed among medical universities based on their applications. The biggest quotas are for the specialties in short supply. However, there is a gap between quotas and the actual applications of medical universities ( 18 ). The latter are interested in increasing the number of students who pay for their training. These are the students in the most popular specialties of gynecologists, urologists, and dentists who provide services mostly for out-of-pocket payments. A chronic underfunding of medical universities from public sources aggravates the structure of training: it is shifting to specialties with a high “financial return”. Also, medical universities are slow to adjust their capacity to new needs. Only 3 % of them have units for training GPs ( 19 ).

Actionable recommendations

An extensive increase in the number of physicians does not solve the problem of their shortage. It is necessary for federal and regional policymakers to strengthen the policy focus on the structural parameters of human resources and the elimination of their imbalances . The experience of many OECD countries provides good examples of such policies. A range of levers is used, including providing incentives to encourage more doctors to choose a general practice and to foster the take-up of certain specialties that are expected to be in short supply in the future; to expand the roles of nurses and other non-physician providers to reduce pressures on physicians. In post-graduate training, there is a search for a new balance between general practitioners and specialists. For example, in France, 48% of medical graduates go to residency in general practice ( 20 ). These trends are very relevant to Russia.

Also, the mechanisms to overcome the hospital-centered model of service delivery are needed. We can suggest (a) strengthening control over opening new positions of hospital doctors, (b) increasing the capacity of outpatient departments in hospitals and staffing them with oversupplied doctors, and (c) retraining some specialists to general practitioners.

Strengthening health labor planning . First, to develop middle- and long-term plans for 2030 and 2035, respectively. Second, to account for a complex of factors (future morbidity and mortality, changes in medical technology, possible reconfiguration of physicians' and nurses' roles, and shifts in service delivery structure). Third, to use the indicators of shortage that take into account the multiple job-holding and plan its reduction.

Strengthening regulation of postgraduate training structure . To overcome the orientation of medical universities to expand training in oversupplied, well-paying ”commercial“ specialties, it is necessary to increase public funding for medical education. The quotas for post-graduate training should be developed not 1.5 years before the start of admission (as it is now), but 3–4 years before. Universities should have time to change their structure to accommodate the growing number of highly wanted professionals. These quotas should be based on the indicators of strategic forecasts and recruitment plans that may extend up to 10 and 20 years in the future.

Increasing the share of GPs in the total number of physicians from the current 13% to the average for the “new” EU countries −29% ( 19 ) by 2030. Use financial and nonfinancial incentives for doctors who choose general practice. Cancel the current practice of ”simplified accreditation” of primary care physicians and take a course on modern postgraduate training of GPs. This will strengthen the capacity of PHC and decrease the demand for specialists.

The health workforce policy in Russia has recently been activated to overcome the shortage of physicians in the situation of serious labor imbalances. Physicians training is expanding, the regions of the country are increasingly contracting medical universities for post-graduate training of specific specialists, and some financial incentives are used. However, the severity of the problem remains high, mostly in primary care. The main reasons for the reproduction of physicians' deficit are the following: a distorted structure of service provision, the lack of medium- and long-term labor planning, the insufficient regulation of post-graduate training structure across specialties, and the underestimate of the general practitioner's role in reducing demand for outpatient specialists. The major lesson learned is that an extensive increase in the number of physicians without changing their composition does not solve the problem. A structural policy is needed to ensure that the workforce structure is in line with the needs of the health system for the coming decade.

Author contributions

The author confirms being the sole contributor of this work and has approved it for publication.

The article was prepared in the framework of a research grant funded by the Ministry of Science and Higher Education of the Russian Federation (Grant ID: 075-15-2022-928).

Conflict of interest

The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The author is grateful to Professor S. Shishkin and Ms. S. Sazhina for valuable comments and kind assistance.

• Pennsylvania

Dr. Gary F Salak

• MEDICARE CERTIFIED
• 28+ YEARS EXP
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Dr. Gary F Salak, OD, is an Optometry specialist in Moscow, Pennsylvania. He attended and graduated from Pennsylvania College Of Optometry in 1996, having over 28 years of diverse experience, especially in Optometry. Dr. Gary F Salak may accept Medicare Assignment. Call (570) 843-6054 to request Dr. Gary F Salak the information (Medicare information, advice, payment, ...) or simply to book an appointment.

Doctor Profile

Medical specialties.

• Optometry (primary specialty)
• Over 28 years of diverse experience

Credentials

• Doctor of Optometry (OD) help Doctor of Optometry Doctors of Optometry (O.D.s/optometrists) are the independent primary health care professionals for the eye. Optometrists examine, diagnose, treat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye.

Education and Training

• Dr. Gary F Salak attended and graduated from Pennsylvania College Of Optometry in 1996.
• NPI #: 1285684761
• NPI Enumeration Date: Friday, May 12, 2006

Quality Reporting

• eRx - He does not participate in the Medicare Electronic Prescribing (eRx) Incentive Program.
• PQRS - He does not report Quality Measures (PQRS). The Physician Quality Reporting System (PQRS) is a Medicare program encouraging health care professionals and group practices to report information on their quality of care. Quality measures can show how well a health care professional provides care to people with Medicare.
• EHR - He does not use electronic health records (EHR). The Electronic Health Records (EHR) Incentive Program encourages health care professionals to use certified EHR technology in ways that may improve health care. Electronic health records are important because they may improve a health care professional's ability to make well-informed treatment decisions.
• MHI - He does not commit to heart health through the Million Hearts initiative. Million Hearts is a national initiative that encourages health care professionals to report and perform well on activities related to heart health in an effort to prevent heart attacks and strokes.
• MOC - He does not participate in the Medicare Maintenance of Certification Program. A "Maintenance of Certification Program" encourages board certified physicians to continue learning and self-evaluating throughout their medical career.

Language Spoken by Dr. Gary F Salak

Medical licenses, practice locations.

• Monday: 8:00 AM - 5:00 PM
• Tuesday: 8:00 AM - 5:00 PM
• Wednesday: 8:00 AM - 5:00 PM
• Thursday: 8:00 AM - 5:00 PM
• Friday: 8:00 AM - 5:00 PM
• Saturday: Closed
• Sunday: Closed

Contact Dr. Gary F Salak by phone: (570) 843-6054 for verification, detailed information, or booking an appointment before going to.

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