The health of the Russian population continues to lag far behind that in the west. A robust public health response to the high levels of communicable and non-communicable diseases is required. This challenge has attracted considerable attention from international donor agencies and others, but there are still many questions about how the health situation in Russia is understood by policy-makers within the country and what responses are being considered. This paper examines these questions by means of a review of literature published in Russia and interviews with key informants. It concludes that although many of the determinants of health in Russia have been identified, they are typically discussed in a general way. Research on the major determinants of disease in Russia, and published in the international literature, appears to have had little impact. The need for reform to enhance the public health response is recognized. Goals of reform have been described but are poorly defined and there is typically little relationship between a stated goal and the strategy proposed to achieve it. There is a lack of clarity about what is meant by public health, and key concepts, such as inter-sectoral and multi-disciplinary working, are either ignored or misunderstood. Evidence of capacity for managed change is weak. There is an urgent need to create a shared awareness of evidence on the nature of the health challenges facing Russia and the evidence base for both the content of potential responses and the strategies that might be adopted to implement them.