Semashko Model

Origins and establishment

The Semashko model grew out of the zemstvo medicine of the Russian Empire. Introduced soon after the abolition of serfdom in 1861, zemstvo medicine organized care on a territorial district basis, and this district principle survived to the end of the Soviet period, with many zemstvo surgeries converted into rural feldsher-midwife stations (FAPs). At the end of the nineteenth century a commission of the Ministry of Internal Affairs worked out norms for supplying the population with medical care and raised the need for centralized management of health care through a dedicated ministry; a Main Directorate of State Health Care was set up by imperial decree in late 1916 but was abolished in February 1917.

After the October Revolution of 1917 the project became a task of the new state. A decree of July 1918 nationalized existing medical institutions and proclaimed health care free for all, so that, at least nominally, the world's first free and universal health care system was established. On 10 July 1918 the constitution adopted by the Fifth All-Russian Congress of Soviets listed the newly created People's Commissariat for Health, the world's first supreme state body to take charge of all medical and sanitary affairs in the country. Nikolai Semashko, a physician and Bolshevik who became the first People's Commissar for Health, led the elaboration of the system's theoretical foundations.

The theoretical basis of the new system continued the health reform debates of the imperial period, which Semashko formulated as a completed system. Practical gains were slower: in an impoverished country after the civil war and two world wars, access to care, especially in remote villages, lagged well into the 1930s, and practical universality was established only by the 1950s.

Organizing principles

All medical institutions became state enterprises and all physicians became state employees paid from the national budget; private medical practice was not permitted. Care is delivered through a hierarchy of state institutions under the supervision of the Ministry of Health, and in the USSR the whole territory was divided into districts with outpatient hospitals and local physicians assigned to each. The rural feldsher and the district physician who provided first-contact care were broadly trained specialists able to diagnose and treat the most common diseases, while more complicated cases were referred through the referral system to city, provincial, republican and all-union levels. In all, Soviet health care had five levels of service delivery.

Prevention and social hygiene were proclaimed the cornerstone of state health policy. Preventive work included universal vaccination, promotion of healthy living and physical culture, and a system of rest homes and sanatoria, and a sanitary-epidemiological service was created for preventive sanitary supervision and epidemic control. Semashko understood prevention more broadly still, including measures to address the housing question; on his initiative water filtration systems were modernized or rebuilt in most large Soviet cities. Networks of dispensaries (tuberculosis, psychoneurological, dermatovenerological and others) were organized to register and treat social infectious and chronic diseases.

Dispensarization is a distinctive institution of the model: every detected case of a serious disease is subject to a set of guidelines covering planned curative activities, their documentation, the required number of contacts with specialists, and monitoring and outcome indicators, with detailed guidelines developed later, in the late 1960s. The People's Commissariat for Health, however, never succeeded in centralizing all medical care in one ministry: the transport and defence commissariats built their own independent medical networks, and a network for the country's top leadership existed within the commissariat but was in practice independent of it.

International spread

The Semashko model was the first experience of building a single nationwide system of medical provision, and it was studied and used in designing the analogous Beveridge system adopted in the United Kingdom and elsewhere. Sweden, Ireland, the United Kingdom, Denmark, Italy and other developed countries built their budget-funded health systems drawing on the Soviet system and on the Beveridge system that emerged after the Second World War. Various versions were adopted in the socialist bloc.

In Cuba reform began in 1960 with the creation of a rural health service and the nationalization of health and pharmaceutical enterprises, and the pre-revolutionary urban network of mutual-aid clinics was converted into policlinics that formed the lower level of the Semashko model. The system was fully state-financed and free for Cuban citizens from the outset, but the legal guarantee of universal free care came only in 1983. In 1984 a family doctor programme was introduced at the lower level: broadly trained physicians established long-term relationships with families, provided first aid and outpatient care and followed their patients in hospital, usually living in the same area and serving on average about 150 families. Soviet assistance played a decisive role in building Cuba's health sector, with Soviet supplies accounting for more than 90 per cent of medical equipment and medicines in the 1960s to 1980s. The collapse of the USSR hit Cuban health care hard, and the crisis of the 1990s was overcome through cooperation in medical education, exports of medical services and import substitution in pharmaceutical raw materials.

Reform and assessment

During the stagnation of the 1970s the model underwent a deep revision that shifted the emphasis from the district physician to specialist care in the district policlinic, harming the qualifications and prestige of district internists, who became in effect dispatchers referring patients to specialists. These reforms marked a departure from the Semashko model toward one focused on specialized outpatient care.

The model substantially improved population health relative to the starting point of its implementation, and vaccination, dispensarization and anti-epidemic work reduced epidemic risks almost to nothing. It was nevertheless less effective against non-communicable diseases and failed to advance population health further, and it has been criticized for a rigid, highly centralized and prescriptive design with a strong focus on specialist medicine that left family medicine and primary care underdeveloped. Because the district principle gave patients no choice of physician, competition between doctors and interest in the patient were absent. Scholarship is divided over whether the system's weak response to rising chronic disease reflected fundamental flaws of the model or the excessive bureaucratization and rigidity of its implementation. Chronic underfunding led to shortages of medicines and modern equipment and to informal payments for care, widespread in the late Soviet period, though some researchers argue that underfunding was a consequence of Soviet internal policy rather than a fundamental defect of the Semashko system.

After the collapse of the USSR each republic chose its own path. Russia and most post-Soviet states retained the model but reformed it toward less centralization and a greater share of paid services, while Turkmenistan, Kyrgyzstan and the Baltic states moved away from it. A 2018 study found that Russian primary care retains positive features such as financial accessibility of care and a focus on prevention but is inefficient and of low quality by international standards, attributing this to the excessive specialization of primary care, the delay in the shift to a general practitioner model, and the dominance of the multispecialty policlinic.