Study of Citizens of CIS Countries Receiving Medical Services on the Territory of the Russian Federation: Insights for Development of the Export of Medical Services (Based on Material of Focus Group Interviews)

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Justification
The export of medical services is one of the fastest growing areas in the structure of the world economy. At the same time, this direction seems to be promising in terms of health care development, since it meets the needs of foreign patients in medical services inaccessible or inaccessible in their country and, at the same time, makes a significant contribution to the extra-budgetary income of medical organizations of the "host country".
On May 7, 2018, the President of the Russian Federation V.V. Putin signed the Decree "On national goals and strategic objectives for the development of the Russian Federation for the period up to 2024", which, among other things, indicated the need to increase "the volume of exports of medical services at least four times compared to 2017 (up to 1 billion US dollars per year) ”[1]. In order to develop the export of medical services, from January 1, 2019, within the framework of the national project "Healthcare", the Federal project "Development of the export of medical services" was launched [2].
In 2020, the indicator "an increase in the volume of exports of medical services by at least four times compared to 2017 (up to 1 billion US dollars per year)" of the national project "Healthcare" amounted to 196.97 million US dollars. The indicator “the number of foreign citizens treated in medical institutions of the Russian Federation, thousand people. cumulative total ”amounted to 3969.15 thousand people.
It should be noted that at the moment the largest number of foreign citizens who receive Russian medical services are residents of the CIS countries, which is due, among other things, to territorial and historical proximity, the absence of a language barrier and visa accessibility [3]. In 2020, the number of treated foreign citizens from the CIS countries who received medical services on the territory of the Russian Federation amounted to 1.6 million people. The volume of services amounted to $ 63 million. Thus, it is patients from the CIS countries that make the greatest contribution to the formation of indicators of the export of medical services in the Russian Federation. The most demanded profiles of medical care among foreign patients of the CIS countries are cardiology, ophthalmology, check-up, reproductive medicine, dentistry.

It should be additionally noted that the export of medical services must certainly be systemic, regulated and not spontaneous. Thus, for an exporting country of medical services, targeted entry of foreign citizens is optimal, mainly for those medical services that are positioned by the exporting country as available for export.
In 2019, the most profitable constituent entities of the Russian Federation in terms of the amount of proceeds were Moscow, Moscow Region, St. Petersburg [3, 4]. It can be assumed that these entities, especially taking into account the activity in holding international events and the increased number of foreign tourists, also make the largest contribution to the volume of proceeds from the export of medical services.
According to an expert survey conducted as part of a marketing study of Russian exports of medical services, it can be concluded that most experts consider external and internal medical tourism "promising directions for the development of healthcare in the Russian Federation - 61.3% of respondents agreed with this statement." In addition, “representatives of all expert groups are convinced that there are opportunities for the RF to enter the international medical tourism market - 75.4% of respondents, and only 9.8% are sure that there is no such opportunity” [3].
All of the above allows us to state the relevance and need for further research in the field of medical tourism and the export of medical services. Increasing the volume of export of medical services is possible only with the use of competent marketing solutions. The development of these decisions should also be based on the conduct of relevant sociological research, including, inter alia, the study of opinions about Russian medicine among foreign citizens.

The research carried out by the authors allows us to form an idea of ​​the opinion of real recipients of medical services about Russian medicine among foreign citizens of the CIS countries, which in turn can be used to form an effective strategy for promoting the export of medical services, taking into account the real needs of the target audience. At the same time, from the point of view of the authors, who recognize the contribution of inpatient care to the development of the export of medical services and the achievement of the set goals, outpatient care also plays an important role. Due to the prevalence of this type of assistance, many foreign citizens living on the territory of the Russian Federation have real experience of receiving it, which can have a significant impact on the image of Russian medicine broadcast by them, and ultimately also affect the overall capabilities of the Russian Federation in the development of medical tourism and export of medical services.

Purpose of the study: to study the opinion of Russian medicine among foreign citizens of the CIS countries (as the largest group of foreigners - recipients of medical services) living in the Russian Federation, in order to form an effective strategy for promoting medical services among foreigners provided in the Russian Federation.

Methods
Study design
A qualitative study was carried out using the online focus group method according to a semi-formalized guide. The focus group participants were foreign citizens living in Russia. The duration of each focus group was no more than one and a half hours.
Compliance criteria
For the selection of participants, a special screening questionnaire was used, which included the following parameters:
• Geography of participants' coverage - foreign citizens living in the Russian Federation for more than half a year, who have moved from the CIS countries.
• Experience - having real experience in getting medical services, not just getting certificates.
• Attitude towards medicine - respondents should not be medical professionals.
• Cultural and religious factor - holding two focus groups with Muslim respondents was conditioned by incl. studying the needs and attitudes towards halal medicine. The rest of the focus groups included representatives of other religious cultures (non-Muslims).
• Socio-demographic characteristics - the survey should include respondents of different sex and age.
• It was also important to cover such a specific group of foreign citizens as students of medical universities and faculties, which could potentially have an impact on the promotion of Russian medicine among compatriots.
The final parameters of the groups were as follows:
1. Muslims, 18-34 years old, NOT medical professionals, NOT medical students, 1 / 3-2 / 3 of the participants are men.
2. Muslims, over 35 years old, NOT medical professionals, 1 / 3-2 / 3 of the participants are men.
3. Non-Muslims, 18-34 years old, NOT medical professionals, NOT medical students, 1 / 3-2 / 3 of the participants are men.
4. Non-Muslims, over 35 years old, NOT medical professionals, 1 / 3-2 / 3 of the participants are men.
5. Students of medical universities and faculties (1 / 2-1 / 3 Muslims, 1 / 2-1 / 3 women).

Conditions of conducting
ANO IC "Discourse" provided assistance in recruiting respondents. Focus groups were conducted online due to pandemic restrictions. The moderator of the groups was an employee of the Department of Medical and Sociological Research of the State Budgetary Institution "NIIOZMM DZM".
Study duration
The first online focus group was held on December 3, 2020, the second and third groups on December 4, 2020, and the fourth and fifth groups were held on December 7, 2020.
Description of the medical intervention
Not provided.
Study outcomes
The main outcome of the study: Recommendations on the directions of promoting domestic medical services in the CIS countries.
Additional research outcomes: A case study of the application of the COM-B and BCW (Behavior Wheel) [5] techniques to develop recommendations for the promotion of domestic medical services in the CIS countries.
Subgroup analysis
Qualitative methods of data analysis were used, quantitative statistical analysis in subgroups was not carried out. The adapted structure of the “ability-motivation-opportunity-behavior” (COM-B) model [5], which is used today, among other things, by the World Health Organization [6], was used as a theoretical basis.

Outcome registration methods
Using coding categories for text analysis. The resulting coding categories made it possible to subsequently apply the COM-B and BCW methods to generalize and develop recommendations for the promotion of medical services received in Russia among foreigners.
Ethical review
Not provided due to the absence of risks for the respondents. Participation in the study was voluntary and paid, the respondents had the opportunity, without any subsequent sanctions, not to participate in the discussion of undesirable topics for them.
Statistical analysis
Sample size calculation principles:
The average number of participants in each of the 5 focus groups was 8 people. According to the principles of constructing a theoretical sample [7], the goal of a quantitative representation of the target group was not pursued; the goal was to identify the maximum variation of opinions on the topic, allowing the most complete description of the ongoing process. Thus, the socio-demographic characteristics of the respondents were used not to quantitatively represent the target audience, but to achieve the representation of groups with the most diverse experience and cultural background. According to methodological requirements, the composition of focus group participants was determined taking into account the need to observe homogeneity (for example, age and religion) and differentiation (gender) of characteristics.

Methods of statistical data analysis: the software package for the analysis of qualitative (including textual) data ATLAS.ti 9 Windows was used. The study was not aimed at revealing the prevalence of opinions, statistical criteria were not used.
results
Subjects (participants) of the study
The target audience is foreign citizens, namely men and women over the age of 18, living in the Russian Federation for more than six months, with a level of knowledge of the Russian language sufficient to participate in a group discussion, with experience in obtaining medical services on the territory of the Russian Federation. At least one citizen from each of the CIS member states (active and excluded), except for Azerbaijan and Russia (10 states), took part in the study. The choice of representatives of the CIS countries is justified by the fact that today they constitute the overwhelming majority of those foreigners who receive assistance in our country [3, 4].
Key research findings
General provisions required for analysis
To collect information, the authors prepared a focus group interview guide, compiled in accordance with the goals and objectives of the study. Within the framework of the guide, the most relevant topics were touched upon: the experience of receiving medical services in Russia and at home, the main differences, disadvantages and advantages, difficulties and barriers faced by informants, as well as motivation and attitudes towards the export of medical services, ways of disseminating information about opportunities medical tourism in Russia.

Based on the results of the analysis of the focus group interviews, it can be concluded that in fact, half of the participants in the discussion say that they rarely go to medical institutions, it was often noted that the call takes place if assistance cannot be postponed (for example, for emergency medical care). , to dentistry in case of acute pain, etc.).
Despite this, the participants have quite extensive experience in obtaining medical services both in Russia and in their own country, are competent in discussing the Russian health care system, have approximately equal experience in contacting both public and private medical institutions.
B. (f., 34 years old, Kyrgyzstan): Before, almost 100% turned to private ones. But now everything has changed. Already some part of people go to budgetary institutions, according to the policy, receive medical care and receive treatment.
All focus group participants lived in the city of Moscow, and based on the analysis carried out, it can be concluded that for them Moscow was perceived as the basis of the image of Russian medicine and its main brand. The experience of receiving medical services for many is also limited to Moscow. Participants in the study often compared not the level of medicine in their country and in Russia as a whole, but compared the level of medicine in Moscow in large cities of their homeland (Kiev, Minsk, Tashkent, Nursultan).
The image of Russian medicine as a whole, which was also discussed with the participants, was formed on the basis of general ideas, as well as the limited personal experience of individual informants, and differs unfavorably from the image of Moscow medicine.
Yu. (Female, 18 years old, Kazakhstan): I cannot say specifically about all Russian medicine. But the Moscow one is still better. Because there are specialists. It seems to me that good specialists from all over the country go there. Because the qualifications are immediately visible.

If we talk about comparing medicine in Russia and in our country, there were different opinions. For example, a comparable level of Russian medicine was discussed in the context of the similarity of post-Soviet health care systems (for example, Belarus), and respondents from poorer countries spoke about the superiority of Russian medicine, arguing their point of view with poorer equipment in their country and a higher incidence of shadow payments.

Analysis Framework - COM-B Model
An adapted structure of the “ability-motivation-opportunity-behavior” (COM-B) model [5] was used as a tool for analysis, with the help of which it is possible to identify behavioral barriers and ways to overcome them (see Fig. 1):
o Ability, for example, knowledge of the available medical care options for foreign nationals.
o Motivation, for example, attitude, confidence in the quality of assistance, confidence in the qualifications of the specialists providing it.
o Social opportunities, e.g. social support, social norms
o Physical capabilities, for example, the absence of physical restrictions, the availability of finance, legal regulation, the availability of information in publicly available sources, etc.

Figure 1 - Model COM-B.
This model was used in the analysis because of its proven efficacy in many previous health studies, as well as on the basis of its suitability for the research objectives. In particular, we were interested in the opportunities provided by the model to analyze the situation, isolating in it the prerequisites for the necessary change in behavior (in this case, the greater appeal of foreigners for medical services to Russia).

COM-B - Physical Capabilities
The physical capabilities within the framework of this model can be primarily attributed to the legislative regulation of the ability of foreign citizens to receive medical care, to use the "State Services" service to make an appointment with a doctor, as well as financial capabilities to pay for medical services. In this case, there are differences between citizens of the EAEU countries and other foreign recipients of medical services on the territory of the Russian Federation.
Based on international agreements, citizens of the EAEU member states (Armenia, Belarus, Kazakhstan, Kyrgyzstan), in comparison with citizens of other states, have some preferences in obtaining medical care: citizens of these states officially working on the territory of the Russian Federation from 01.01.2017 have the right to free registration of the compulsory medical insurance policy [8]. The paper policy is valid until the end of the calendar year, but cannot be valid longer than the expiration date of the employment contract. At the same time, “emergency medical care (in emergency and urgent forms) is provided to workers of the Member States and family members by medical organizations (health care institutions) of the state and municipal health care systems of the state of employment free of charge, regardless of the availability of a medical insurance policy” [9]. It is no coincidence that at focus groups, citizens of the EAEU countries discussed cases of free assistance.

B. (female, 34 years old, Kyrgyzstan): But since we kind of entered the customs union, we have such a privilege ... It turns out, if we have a registration, an employment contract, respectively, we can get medical insurance, this is and there is, as it were, a policy. And with this policy, we can already apply to budgetary and government agencies. It is already more convenient and good.
I. (m., 35 years old, Uzbekistan): 3 years ago my wife had an operation here, she had appendicitis. Somehow they did it for free, I myself did not understand why it is free.
Citizens of countries outside the EAEU face greater challenges in terms of access to assistance. Based on the results of focus groups, 3 main strategies for obtaining medical services in Russia by citizens of these states were identified:
1. Scheduled appeal to private medical institutions or to paid departments of budgetary institutions:
A. (female, 34 years old, Turkmenistan): I applied to a budgetary organization - they do not serve me, so I go to private ones.
2. Emergencies, seeking emergency medical help:
M. (female, 54 years old, Tajikistan): Yes, I am also ill, I also have high blood pressure. When this happened to me, my head ached, we wanted to call an ambulance. They gave me first aid.
3. Purchase of an insurance policy and a planned visit to a state medical institution:
B. (female, 46 years old, Tajikistan): I made myself an insurance policy and often go to the clinic.
At the same time, some respondents noted that the purchase of an insurance policy in their case had a number of disadvantages, including: high cost, difficulties in interacting with an insurance organization, coordination of services, in particular, it was noted that checking documents, insurance policies, significantly slows down the timing of assistance. In addition, a narrowed list of available services was also mentioned. Often the problem of insurance was raised by medical students.

A. (male, 23 years old, Tajikistan): For example, a person had an [injury], it is clear that he urgently needs to do something, but he simply forgot his documents at home or some of the documents are missing. This should not play the role that everything, the process is stopped and said: "Everything, without this it is impossible." …. How can I apply? First of all, they will ask for documents, they check everything inside and out. While you have something serious there, they do not understand what they are doing. And while they demand to contact the insurance company, which in principle you do not need, you are wasting a lot of time.
As a separate inconvenience that needs to be mentioned, the focus groups noted the inaccessibility for foreign citizens of all countries to register through the "Gosuslugi" portal, i.e. the need for face-to-face contact for recording.
E. (f., 19 years old, Armenia): So I signed up three weeks ago, and there was a queue for three weeks, everyone was already recorded there, that is, those who have Russian policies. And they are recorded through the "Gosuslugi" portal. That is, they have an application. ... They constantly tell me that the recording will open, sign up. They think that I have a Russian policy. Then I say that I have not. And they say: "Well, you will come, then, at 7 in the morning, when the recording opens." But what's the point for me to go at 7 in the morning? Or maybe it won't happen again, and this is a closed circle.
The data obtained show the need for greater regulation of the provision of medical services to citizens of the CIS countries, especially to citizens of countries outside the EAEU. The factor of high cost and organizational difficulties (including obtaining insurance) can significantly neutralize positive perceptions about the quality of care, the level of equipment, etc. Moreover, such ideas about medical care can be transmitted to the homeland even in the absence of direct experience of seeking help, such a campaign can be expressed by the statement: “I haven’t applied, but they say that it is expensive and difficult”.

COM-B - Abilities
Earlier it was noted that the citizens of the EAEU have more opportunities to seek medical care in the Russian Federation within the framework of agreements between the countries.
At the same time, not all focus group participants from these countries knew about the availability of both opportunities for registering compulsory medical insurance and opportunities for receiving free medical care in emergency and urgent forms.
N. (female, 21 years old, Kazakhstan): There were no unnecessary questions, they helped ... I didn’t even know that I was in the customs union and could go to ordinary clinics. I thought it was either insurance or paid.
It can be concluded that in order to remove some barriers in obtaining medical care by citizens of the EAEU member states, their information should include up-to-date data on the possibilities and limitations of obtaining compulsory medical insurance for foreign citizens: is registration necessary, what documents are needed to issue compulsory medical insurance, what are employment contracts, whether family members can count on help, etc.

COM-B - Motivation
As a motivation for contacting Russian medical institutions, one can name the respondents' ideas about the high level of qualifications of Russian doctors, as well as about the technical equipment of Moscow organizations.
According to the majority of participants, complex medical operations requiring high skill and qualifications can be carried out in Moscow. Of interest are "modern" areas - plastic surgery, reproductive health, highly specialized surgery, neurology, etc.
B. (male, 22 years old, Kyrgyzstan): My brother had a problem with his shoulder, and there we did not have doctors who were associated with just such an injury. And we also came to Moscow. We did an operation in Moscow.
T. (f., 38 years old, Belarus): In terms of complex diseases, some and some surgical interventions, where masterly work is required ... If the disease is specific, or complex, especially my opinion, what concerns the brain , I suppose, you definitely need to contact Moscow.
Almost all respondents, regardless of citizenship, say that Moscow healthcare has an advantage in terms of technical equipment.
N. (male, 43 years old, Kyrgyzstan): Here, that is, in terms of equipment, material base - it is very, very well organized.
At the same time, a significant contribution to the appeal of foreign citizens to Russian medical institutions can also be provided by ideas about how they contact medical organizations (is it easy to get help?) Or about the service characteristics of help.

Since the appeal of respondents to state medical institutions is associated with bureaucratic obstacles, the "negative" image of state medical care can add up even before the moment of appeal. Often, the image is based precisely on the perception of the complexity of communication with employees of medical organizations, and not on the quality of the help itself (it is difficult to get help, it is difficult to prove your right to receive it). In this vein, it is worth noting that the ambulance has the most positive image, because it is provided to all citizens, regardless of citizenship and the presence of a policy. One of the ways to avoid these difficulties is to apply to private medical organizations on a paid basis, because it is “easier and faster” this way, and you also have to pay for some services in public medical organizations.
So, contacting private medical organizations is associated with:
1. The quality of the assistance provided:
V. (female, 31 years old, Belarus): I think a paid clinic, of course, is better, of better quality, because this is a better quality specialist, he will be paid for it.
V. (male, 20 years old, Belarus): Naturally, in private equipment, it is no longer of Russian production, and it is at a level higher than in ordinary [polyclinics].
Although it is worth noting that the appeal to private organizations was also not always characterized positively. Informants expressed fears that contacting private clinics is associated with "pulling" money from clients:
R. (male, 45 years old, Turkmenistan): In my case, the fact that we pass additional tests is again due to the fact that you can be “put on” there for additional money. This is if we are talking about the private sector.
It was also noted that the receipt of medical services in private clinics did not always meet the expectations regarding quality:
S. (male, 41 years old, Belarus): That is, they are trying to earn money, but they do not do their job well. That is, the concept of "ethics" is absent from some specialists.

2. Higher level of service / maintenance:
K. (f., 28 years old, Georgia): The service is better there - roughly speaking, they lick from the doorway when you enter.
However, speaking about the service, it should be mentioned that, in general, during focus group interviews, the respondents did not often talk about the level of service in medical organizations in Russia and in their countries. This may be due to the level of the respondents' earnings, which does not imply the pursuit of the highest level of service: they are more result-oriented, and service issues may fade into the background.
3. Saving time:
V. (f., 31 years old, Ukraine): I urgently needed a certificate from a music school, I called, the next day I arrived at the appointment, looked at the pediatrician, everyone smiled, red carpet, paid money and left - no queue, nothing.
Separately, it is worth noting the problem that was mentioned both in relation to private and state medical organizations: the respondents have a feeling of "inattention" to them on the part of medical workers:
A. (male, 31 years old, Ukraine):… I don’t know, maybe people have become angrier. Most likely it depends on it. The impression is that they are “playing football”, they want to quickly relieve themselves of responsibility in order to drive you around. Nobody wants to answer for anything - that's my opinion. There is a turnover in Moscow. And lately, as I said, they want to say goodbye to you and do everything as quickly as possible, send them away, say: “This is not in my qualifications, specialty” ... It is the same whether it is paid or here. Nobody wants to bother too much. Because the flow of people, and faster, faster, so as not to get hung up on you.
The feeling of a "conveyor belt" when providing care, especially in contrast to their home country, where many have familiar doctors, makes a negative impression (this mainly concerns the outpatient level (“in hospitals, everything is different, and there are normal people, everything is fine ”), And was often associated by respondents with their migrant status).

As noted earlier, many migrants prefer not to seek medical help unless urgently needed, in some cases preferring to “wait” for the trip home and recover there. In view of this, in order to be attractive, it is not enough for Russian medicine to have advantages. These advantages should be perceived as sufficient in order to overcome the convenience of conservative respondents referring to “their own”, “native”, “familiar”, as well as the fear of “someone else's”:
A. (male, 23 years old, Tajikistan): I decided to do all this at home, because there are acquaintances there, more reliable.
T. (f., 38 years old, Belarus): I endure to the last and go to Belarus. Because I have proven doctors there, and they provide really high-quality medical care, I am confident in them.
Another important factor in terms of motivation for choosing treatment in Russia is the “authority” of the country's health care in a certain area, because “if a person has a specific disease, they go abroad” (A., female, 34 years old, Turkmenistan ").
The absence of a specific “niche” in the provision of medical services, where Russia would be perceived as a market leader, can have a negative impact on the ability to attract clients.
A. (male, 31 years old, Ukraine): Why are more and more people going abroad for treatment? For example, Israel makes teeth well; in matters related to digestion, it is better to go to Germany. I have never heard someone say “go to Russia and treat this and that”, it seems to me that there is no such thing.
An additional negative factor is the perceived high cost of Moscow medicine: it is cheaper to “come home and do it”. Here it is worth mentioning that the conversation is primarily about the services of low and medium price categories.
It is a matter of particular concern that during the focus group with medical students from the CIS countries, a critical attitude towards Russian medicine was often sounded due to the fact that they face many problems (for example, the acquisition and use of insurance, which they consider to be essentially forced and useless) ... The identified difficulties prevent the use of this potentially powerful resource of medical “promoters” (promotion of Russian medicine among their compatriots), despite the fact that development as specialists in Russian medicine for many students is seen as more promising than further development as specialists in their own country.

COM-B - Social Opportunities
Social opportunities that can be used include the cultural, linguistic and territorial closeness noted by the participants, the remaining ties (personal, economic) from the times of the USSR, which can also be considered as additional advantages.
N. (female, 21 years old, Kazakhstan): Since Kazakhstan and Russia are probably a little more closely related, so all the equipment is sent to us, it is easier for us to come to Novosibirsk for treatment, to fly to Moscow, to Omsk, because it is money is not so much different than in Kazakhstan ...
In this regard, one cannot but touch upon the religious factor. Thus, for respondents from Muslim countries, the opportunity to receive medical services taking into account their cultural characteristics (first of all, the coincidence of the sex of the doctor and the patient and the availability of halal food) is quite important, although not strictly necessary.
A. (male, 23 years old, Tajikistan) I think there is such a thing, but not much. If my sister needs to examine me, even if an injection is given, it does not greatly affect. And the fact that there is gynecological, something more serious, it would be better if men were served by men, and women by women.
N. (female, 21 years old, Kazakhstan): I think this is very important about halal. When people come from Kazakhstan and not only from Kazakhstan, from Muslim countries, food is probably important for them.

Social opportunities should also include the channels through which informants received information about medical services, what sources of information they were guided by when choosing medical institutions or specialists for treatment. There are certain specifics in this issue.

Based on the results of the focus groups, it was revealed that for the respondents, the leading and preferable are mainly informal channels of communication about services, and it is desirable to focus on them when promoting Russian medicine. So, often, first, there is an appeal for advice (to which doctor to contact? Which organization?) due to the perceived large number of "fake" reviews), websites of medical organizations.
Additional research findings
The block is combined with the main results.
Adverse events
None.

Discussion
Summary of the main research finding
The study made it possible to identify a range of existing shortcomings that affect the promotion of Russian medicine by foreigners among compatriots. These may include difficulties in communicating with health workers when applying, problems in interacting with insurance companies, perceived high cost, "conveyor" nature of medicine. For the development of the export of medical services and medical tourism, it is equally important not only to eliminate the shortcomings, but also to focus on the strengths of domestic medicine.
Discussion of the main research result
Framework for summarizing insights gained - BCW model
The authors of the BCW methodology S. Michie, M. M van Stralen, R. West in their work proposed a structure aimed at changing behavior. It is based on the elements of the behavior system (ability-motivation-opportunity), as well as nine options for actions aimed at changing human behavior (interventions). Moreover, each element of the system of behavior corresponds to a certain set of interventions (see Table 1):

Based on the analysis of materials from focus group interviews, incl. suggestions from the informants themselves, the main directions for work were identified in accordance with the interventions justified in the BCW methodology. Further in the article, the recommendations are structured not according to the compliance with the COM-B components and the necessary interventions, but based on the main blocks of the strategy for the development of the export of medical services and medical tourism.

What needs to be worked on in general
- Informing (working with the element of "ability", intervention - "training"). Taking into account the fact that not all informants know about their rights and opportunities in the field of receiving medical care, it is important to carry out information work in this direction (cooperation with employers and the migration service is possible). Taking into account the different possibilities, information should include up-to-date data on the available opportunities and limitations separately for citizens of the EAEU countries and other states.
- Simplification of receiving outpatient care for migrants and foreigners (work with the elements of "physical opportunity", "motivation"; intervention - "environmental change"), for example, the possibility of combining high-quality insurance with a residence permit, this is especially critical for students of medical universities, who can later become “promoters” of Russian medicine (work with the “motivation” element, intervention - “training”).
- Development of insurance programs in the "all inclusive" format, taking into account their real availability (work with the element "physical opportunity", intervention - "creating an opportunity").

- Creation of the image of the country, "the best" in certain medical areas, similar to other countries, such as, for example, South Korea [3] (work with the element of "motivation", intervention - "modeling").
- Creation of a service that is as friendly as possible for a foreigner, taking into account his cultural, religious characteristics (working with the element of "social opportunities", intervention - "changing the environment").

What to advertise (service form)
- All-inclusive service packages, service designers that provide easy access to medical care, removal of existing bureaucratic barriers and other organizational difficulties (work with the element "physical opportunity", interventions - "environmental change", "creation of opportunity").
A. (male, 23 years old, Tajikistan): There are people who are specifically involved in this project in general, who provide, buy you, I don’t know, a ticket, they will provide you with everything, bring and take away, although it costs the same.

What should be in advertising
- Emphasizing a cheaper price in comparison with competitors from Europe and Asia (work with the element of "motivation", intervention - "persuasion").
- Availability of the best equipment in comparison with the native (for a foreigner) country (work with the element of "motivation", intervention - "persuasion").
- Emphasizing the presence of specialization in narrower areas of medicine (working with the element of "motivation", intervention - "persuasion").
- State guarantee (official protection against fraud and overpayments) (work with the element "motivation", intervention - "environmental change")
- The presence of high-status doctors (facts confirming their world level) (work with the element of "motivation", intervention - "persuasion")
At the same time, the dissemination of information should take into account the specifics of the channels of obtaining information used by migrants (priority appeal to the personal experience of acquaintances) and only then involve other channels (work with the element of "social opportunities", intervention - "environmental change"):
M. (male, 23 years old, Turkmenistan): They liked it there, they come, they say: “It's cheap, good, and doesn't hurt there”
N. (male, 43 years old, Kyrgyzstan): Friends, acquaintances, our migrants, there are groups in WhatsApp too.

Possible ad / promotion format
- Cooperation with the authorities of the CIS countries (embassies, governments) for advertising services (working with the element "physical opportunity", intervention - "creating an opportunity").
R. (male, 45 years old, Turkmenistan): Some kind of international agreement directly between states. And on the embassy's resource, place a tab on the provision of medical care for the citizens of Turkmenistan. But this, probably, should be an agreement already at the ministerial level.
- Targeting: for young people - advertising through social networks and with the involvement of celebrities, for the older generation - TV and outdoor advertising. It is necessary to consider the possibility of attracting "ambassadors", for example, media doctors known to the respondents, such as L. Roshal or A. Myasnikov (working with the element "motivation", intervention - "modeling").
V. (f., 20 years old, Belarus): Now most people trust bloggers to everyone, well, at least young people up to 35.
B. (male, 34 years old, Kyrgyzstan): ... we listened to Channel One, Russia 24, Russia.tv and Channel One ... through television.
- Creation of a website with an aggregator of independent review sites, the ability to choose from several specialists, for example, through promotional consultations (work with the element "motivation", intervention - "changing the environment", "modeling", "persuasion").
A. (female, 35 years old, Belarus): That is, whatever we say, in any case, these are some kind of feedback. I know that there are portals "dock-dock", "honey-honey", and something else, where you open and can, in principle, drive in any doctor, see.
S. (male, 41 years old, Belarus): Leave reviews ... which are verified ...

- Attracting "simple" ambassadors ("ordinary", unknown people), actions for them, attracting them to work in organizations, on actions to launch "word of mouth" (work with the element "motivation", interventions - "modeling", "stimulation ").
A. (female, 34 years old, Turkmenistan): Attract those people, migrants, who live here. So that they go to this clinic, they look, check on themselves, and this chain will go further.
- Development of partnerships with medical organizations in the CIS countries. Already today, doctors from the CIS countries refer to good specialists known to them in Russia. In this context, the following narrow areas of medicine are considered promising (work with the element "physical opportunity", intervention - "creating an opportunity"):
T. (female, 20 years old): Local doctors, Kazakhstani, still advise Russian ones.
- Actions (work with the element "motivation", intervention - "stimulation"):
M. (male, 23 years old, Turkmenistan): I can advise that initially, specialists from this clinic, they visit countries, hold seminars, and treat several people there. And as if they showed their professionalism, and gave the address to their clinic, then people could clearly see how they are being treated, and already turn to them on their official website. Maybe at first they would have arranged actions ... They would say: "Initially, we will provide accommodation for a thousand people for free."
How to target ads
In addition to large cities, it is possible to target advertising to border cities far from the capital (for example, large border centers such as Novosibirsk, for border cities of Kazakhstan) (work with the element of "motivation", interventions - "modeling", "persuasion").
N. (female, 21 years old, Kazakhstan): We have the longest border in the whole world, and they [border cities] are located on the border, it is easier for them to fly to the same Novosibirsk, Omsk, Saratov and so on than to us in Nursultan, because it is cheaper.

Research limitations
The study is limited to foreign citizens from 10 operating countries (including associated countries) and excluded CIS members living in Moscow (with the exception of Azerbaijani citizens who were not included in the sample). Other limitations include the impossibility of obtaining statistically substantiated data on the quantitative prevalence of the described opinions and phenomena. The use of the method imposes a limitation on statistical analysis. When interpreting the data, it is necessary to take into account that during focus group interaction, we cannot exclude the influence on the expressed opinions of such factors as: previously expressed opinions of other participants, cultural characteristics of informants, group dynamics of the discussion, discussion framework set by the moderator.
It is also worth noting that the estimates of Russian health care presented in the study were associated in a significant number of cases with state polyclinic care, which, as a rule, is rated worse than inpatient care or private medicine. This fact may also lead to contradiction with data from other studies of the export of medical services and medical tourism, which focused on opinions about inpatient care.

Conclusion
As a result of the study, some important details of the image of Russian medicine in the eyes of citizens of the CIS countries living in Russia and who had experience in seeking medical care on its territory (good equipment, trouble-free ambulance, at the same time, "conveyor", bureaucracy, etc.) .). The study identified the main strategies used by foreign citizens when seeking medical care (in public and private organizations). Insufficient awareness of foreign citizens about their rights in the field of medical provision on the territory of the Russian Federation was revealed. The main channels of communication used by citizens of the CIS countries to select a medical organization / specialist to seek help - first of all, word of mouth - have been identified. Based on the results obtained, within the framework of the COM-B and BCW models, recommendations are presented to eliminate or level some of the identified problems. The presented results can be used to develop measures to expand the export of medical services and medical tourism, as well as used in other studies on this topic. This study also offers opportunities for structuring the flow of foreign patients and limiting the spontaneity of the export of medical services.

About the authors

Elena I. Aksenova

Research Institute for Healthcare Organization and Medical Management

Email: AksenovaEI2@zdrav.mos.ru
ORCID iD: 0000-0003-1600-1641
SPIN-code: 1448-9797

PhD in Economic Sciences, Professor

Russian Federation, Moscow

Ignat V. Bogdan

Research Institute for Healthcare Organization and Medical Management

Email: bogdaniv@zdrav.mos.ru
ORCID iD: 0000-0002-7002-1646
SPIN-code: 1891-5081

PhD in Political Sciences

Russian Federation, 9 Sharikopodshipnikovskaya street, 115088, Moscow

Radik G. Gataulin

The Central Research Institute for Health Organization and Informatics

Email: export@mednet.ru
ORCID iD: 0000-0002-8782-0380
Russian Federation, Moscow

Sabina I. Grin

The Central Research Institute for Health Organization and Informatics

Email: GrinSI@minzdrav.gov.ru
ORCID iD: 0000-0002-0393-1009
SPIN-code: 9264-8105
Russian Federation, Moscow

Kseniia K. Kriukova

The Central Research Institute for Health Organization and Informatics; I.M. Sechenov First Moscow State Medical University (Sechenov University)

Email: KryukovaKK@minzdrav.gov.ru
ORCID iD: 0000-0001-6714-9780
Russian Federation, Moscow; Moscow

Alexandr V. Pravednikov

Research Institute for Healthcare Organization and Medical Management

Email: pravednikovav@zdrav.mos.ru
ORCID iD: 0000-0002-2553-2359
SPIN-code: 4544-5280

PhD in Sociological Sciences

Russian Federation, Moscow

Alla V. Radetskaia

The Central Research Institute for Health Organization and Informatics

Email: radetskaya@mednet.ru
ORCID iD: 0000-0002-0237-4669
Russian Federation, Moscow

Darya P. Chistyakova

Research Institute for Healthcare Organization and Medical Management

Author for correspondence.
Email: chistyakovadp@zdrav.mos.ru
ORCID iD: 0000-0002-8729-9898
SPIN-code: 8799-0909
Russian Federation, Moscow

References

Supplementary files