How the hybrid rules of free and paid medical care affect the post-socialist health system

In some post-socialist countries, the rules of free and paid healthcare are not clear. We study Russia as an example to explore the combination of these rules and their role in the healthcare system. We analyze the legislation defining the rules of free and paid healthcare; compare spending on free and paid services using statistical data; analyze the practices of free and paid healthcare using sociological surveys and in-depth interviews with the heads of state-owned and private clinics. Then we characterize the role the combination of rules plays in the healthcare system by sociological and statistical data. We found that in the combination of paid and free care in Russia, there is no clear distinction between the two principles of payment. Such a combination partially compensates for the insufficient resource provision and for its territorial differentiation. It improves consumer choice of care, supplements the finances of public providers, and increases their flexibility. The fuzzy distinction between paid and free care is used by the government as a means of mitigating the consequences of the underfunding of free care and avoiding the social tensions associated with it. This unclear distinction is not a failure, but a feature of the Russian healthcare system, which is hard to eliminate. The hybrid system makes the healthcare provision more stable, but paid services reinforce inequality in access to medical care and inefficiency in resource utilization.