Objectives:-evaluate the level of fragmentation/integration in the Russian Federation health care -explore tools to strengthen integration with the focus on economic incentives Methods: survey of physicians (1700 in 3 regions of Russia), review of the literature Results:1) the conceptual framework is suggested for the evaluation of health services delivery integration, as well as around 50 indicators for teamwork, coordination and continuity of care. 2) Physicians report low level of teamwork, coordination and continuity of care in Russia. 3) Bundled methods of payment (prospective payment for both outpatient and inpatient care, including repeated admissions) is the most immediately viable approach to encourage integration of providers. In Russia there is a good evidence of the method known as 'policlinic as fundholder' (fundholding method). It creates incentives for policlinics to plan all stages of service delivery, cooperate and communicate with hospitals, refer patients to the best providers, expand activities to avoid aggravations of chronic cases.

Objectives:-evaluate the level of fragmentation/integration in the Russian Federation health care-explore tools to strengthen integration with the focus on economic incentives Methods: survey of physicians (1700 in 3 regions of Russia), review of the literature Results: 1) the conceptual framework is suggested for the evaluation of health services delivery integration, as well as around 50 indicators for teamwork, coordination and continuity of care. 2) Physicians report low level of teamwork, coordination and continuity of care in Russia. 3) Bundled methods of payment (prospective payment for both outpatient and inpatient care, including repeated admissions) is the most immediately viable approach to encourage integration of providers. In Russia there is a good evidence of the method known as 'policlinic as fundholder' (fundholding method). It creates incentives for policlinics to plan all stages of service delivery, cooperate and communicate with hospitals, refer patients to the best providers, expand activities to avoid aggravations of chronic cases.

The paper explores primary health care models in Russia and in Central and Eastern European (CEE) countries. Starting with the similar model, they have taken totally different ways of primary health care transformation, including the role of general practitioner, multispecialty polyclinics and private sector. The comparison of this diversity, based on the conceptual framework of Primary Health Care Activity Monitor in Europe, demonstrated that the scores of primary care in Russia are relatively lower, particularly in the dimensions of accessibility, comprehensiveness, continuity and coordination of care. The score of the selected efficiency indicators is also relatively low. The major reasons for this are discussed, including the lack of strategic vision on the role of primary care, an excessive specialization of primary care and the delay with a shift to a general practitioner model. A debatable issue of primary care extended composition (the involvement of a growing number of specialists) is also addressed. The conceptual presumption that an extended composition presents new opportunities for more integrated care and better performance has not been supported by the evidence. Big multispecialty policlinics in Russia don't demonstrate advantages over solo and group GP practices that dominate in CEE countries. The potential of polyclinics is not used because of the lack of specific activities for integration. It is argued that new specialists in the practices can strengthen primary care only when they support generalists rather than replace them. The lesson learnt from CEE countries is that substantial changes are needed to overcome the lagging status of primary care in Russia, including overcoming the excessive specialization of primary care, the replacement of district physicians by general practitioners, developing the forms of independent practices operating in parallel with polyclinics and competing with them.

HEALTH CARE INTEGRATION IN THE RUSSIAN FEDERATION: CONCEPTUAL FRAMEWORK, EVALUATION, AND NEW INSTRUMENTS 3Fragmentation in organization and discontinuities in the provision of medical care are problems in all healthcare systems, whether it is the mixed public-private system in the USA, national health services in the UK, or insurance-based ones in Western Europe and Russia. In all of these countries, a major challenge is to improve integration in order to improve efficiency and health outcomes. This article assesses issues related to fragmentation and integration in conceptual terms and argues that key attributes of integration are teamwork, coordination, and continuity of care. It then presents a summary of integration problems in Russia and presents the results of a large survey of physicians concerning the attributes of integration. It is argued that the characteristics of the national service delivery model do not ensure integration. The Semashko model of service delivery, although designed as an integrated model, has been distorted under pressure of the process of specialization of care. It is also argued that larger organizational forms of service provision, like policlinics and integrated hospital-policlinics, do not have higher scores of integration indicators than smaller ones. Proposals to improve integration in Russia are presented with the focus on the regular evaluation of integration and fragmentation, regulation of integration activities, enhancing the role of PHC providers, and economic incentives.