Partnership in Healthcare System Sustainability and Resilience: Russian Healthcare System Analysis

Full Text

Justification
In 2020, the global community is faced with an unexpected and serious challenge from a new infectious disease: coronavirus infection. The COVID-19 pandemic has established a political and social focus on the resilience of national health systems to these types of crises. Despite the fact that healthcare systems in many countries were able to quickly adapt to combat the aggressive spread of the pandemic, the specificity of the situation led to large-scale and multidirectional overloads of the healthcare industry. The need to analyze the lessons learned from the experience of countering coronavirus and assess the degree of its impact on the ongoing transformation processes of national health systems demonstrated the relevance of creating a unified supranational approach to analyzing and assessing the resilience of health systems and their resilience to crises. This led to the creation of an international scientific partnership - Partnerships in the context of health systems resilience and their resilience to crises - in collaboration with the London School of Economics and Political Science, the World Economic Forum and the pharmaceutical company AstraZeneca, in which Russian scientists took part along with research groups from such countries. like Great Britain, Germany, Spain, etc.
This manuscript presents the results of the work of a Russian group of researchers in the study of the impact of COVID-19 on the Russian health care system.
The scientific novelty of the study lies in the uniqueness of the framework used for the analysis of the Russian health care system, developed by specialists from the London School of Economics, which allows for the most complete assessment while maintaining the individual characteristics inherent in the health care systems of different countries.
The main goal of the work is to make a significant and long-term contribution to Russian healthcare by developing a set of recommendations aimed at strengthening the resilience of the healthcare sector and resilience to crises. This goal involves not only approbation of the developed framework structure and conducting the appropriate analysis, but also the maximum dissemination of the results obtained, including at the highest state and international levels.

Methods
Study design
For the analysis, the Russian study used a framework model developed by the London School of Economics research group in the context of the Partnership for Health System Sustainability and Resilience in 2020 [1]. The above framework model proposes a methodology for analyzing the resilience of health systems and their resilience to crises based on five areas: health system management; financing; medical personnel; medicines and technologies; organization and provision of medical care. The subject areas have been developed in accordance with the building blocks of health systems presented by WHO. Each subject area of ​​the framework includes several key areas for analysis that assess the resilience of health systems and their resilience to crises. In doing so, the use of the framework model should take into account the diversity and complexity of health systems, and also take into account the conditions under which they operate. Therefore, the framework should serve as a guide for qualitative analysis, rather than a tool for quantitative measurement or direct comparison between countries.
To develop a framework model, the London School of Economics research team synthesized and synthesized publicly available data on the topic of health systems resilience and resilience, including a review of existing framework models. As a result of the analysis, a number of models were identified that were aimed at developing the concept of health system resilience. At the same time, no framework models were found that looked at the resilience of health systems. To ensure the optimal balance of practicality and accuracy of the framework model, subject areas were considered in terms of characteristics and factors inherent in health systems, and not on the basis of external factors (for example, the broader economic context, environmental characteristics) that also affect health systems. ...
The effectiveness of the framework has been tested in eight countries, including Russia. In each country, the study was conducted by independent research groups with the participation of experts who produced a comprehensive analysis of national health systems based on publicly available data. Within the framework of this article, the results of the work of the Russian country team are presented.
Conditions of conducting
Each section of the study draws on the latest publicly available statistics, as well as current health policy trends and authoritative forecasts. In addition to analytical materials, each section includes a set of recommendations aimed at strengthening the resilience of the Russian healthcare sector and resilience to crises. The list of proposed measures is not exhaustive. Moreover, the dynamics of the development of the situation presupposes further study of the issue.
Study duration
The study was conducted from October 2020 to March 2021.

Results and discussion
Health systems management
Sustainability
Among the main goals of the development of the domestic health care system in relation to the research topic, the following are highlighted: increasing life expectancy to 78 years and ensuring sustainable natural growth in the population of the Russian Federation. To achieve these goals, the authorities (federal and regional) have been assigned a wide range of tasks, including creating conditions for improving the quality and availability of medical care; development, implementation and application of new medical technologies; prevention of diseases that pose a danger to others, etc.
A high degree of continuity of political power greatly contributes to the coordination of measures taken and the uniformity of approaches to achieving the set goals, which, in turn, has a positive impact on the sustainability of the health care system.
The above goals and objectives of state policy are legislatively enshrined in a number of interrelated regulatory legal acts. An analysis of the existing regulatory framework governing the healthcare sector shows a high degree of interconnectedness of regulatory legal acts and a minimum number of inaccuracies and gaps (with the exception of the regulation of the situation caused by the pandemic and the telemedicine boom provoked by this situation, which will be discussed below).
At the same time, despite the fact that legislative activity is the prerogative of the authorities, modern Russian legislation provides for mechanisms for the participation of the public (the general population and experts) in the legislative process. Such a system of involving the public in the legislative process is aimed at obtaining feedback on already developed bills and allows the interests of the population to be met when adopting regulatory legal acts. However, this system has two main limitations. Firstly, due to the fact that the placement of new regulatory legal acts is carried out on state Internet platforms, part of the population is not able to get acquainted with the document due to digital illiteracy or lack of necessary resources (computer, Internet). Secondly, the authors see it as necessary to expand the area of ​​participation of citizens and civil associations in the legislative process in terms of their involvement in the independent development of draft laws, collection of signatures and submission to deputies for consideration. This measure will allow a more sensitive response to the needs of the population.

Resilience to crises
Risks similar to the coronavirus pandemic were studied by Russian experts long before its appearance. This is confirmed by the effectively functioning system of federal state sanitary and epidemiological surveillance. The need to maintain a high level of anti-epidemic preparedness, prompt response to biological threats of any nature (natural or deliberate) is also stated in the Strategy for the development of healthcare in the Russian Federation for the period until 2025, approved in 2019 by the decree of the President of the Russian Federation4. In addition, an important role in countering the pandemic was played by the fact that restrictive measures and the deployment of additional beds in Russia began to be carried out much earlier than in China [2]. The measures taken made the epidemic rise in the incidence of a new coronavirus infection smoother and ruled out the possibility of refusal to provide medical care to people in need.
Thus, taking into account the prompt and effective organization of inter-level and interdepartmental interaction in the country, including in terms of timely informing the population about the regulatory framework, official statements of top officials of the state, statistics of infections and other materials related to the pandemic, we can conclude that despite the uniqueness of the pandemic threat situation, the Russian health care system was in many ways well prepared.
At the same time, the authors think it expedient, firstly, to draw the attention of the authorities to the need to improve the Russian legal framework in terms of regulating emergency situations. As noted above, despite the fact that the Russian legislative system is characterized by a high degree of sophistication, the crisis situation caused by the COVID-19 pandemic required adjustments to existing and / or adoption of new regulations at different levels. In addition, the dynamics of the development of the disease required regular analysis and updating of the published guidelines and temporary guidelines. All this, in turn, has multiplied the workload on the management staff. In order to avoid such overloads in the future, it is necessary to ensure the inclusion in existing or the publication of new regulatory legal acts that provide for the basic algorithms of actions in case of emergencies of an epidemiological nature; and also to work out the regulation of the country's withdrawal from the high alert regime and to eliminate the imbalance that has arisen in order not to roll back into the "pre-coronavirus" times, but to evolve on the basis of the experience gained.
In the context of this section, one should also consider such an indicator as the degree of implementation of decisions made. The situation of a pandemic has empirically demonstrated that quite often the population did not fully realize the importance and necessity of implementing the recommendations adopted at the federal or local levels. For example, measures to observe self-isolation of citizens (provision of non-working days) were perceived by many as additional paid leave with walks, visiting guests, etc. According to a sociological survey conducted by NIIOZMM in June 2020, predicting their behavior during the second wave of coronavirus, 54% of respondents were confident in the correctness of the selective approach to compliance with measures, and 5% did not plan to comply with the requirements of the authorities at all, while only 39% of respondents expressed willingness to follow the recommendations of the authorities [3].
Taking into account the above, in order to increase the effectiveness of the measures taken to curb the spread of coronavirus infection, we see the need to take adequate forms of responsibility of the population for their health (and indirectly for the health of the people around them). This concerns the introduction of a system of punishments not only for non-compliance with the self-isolation regime, creating a threat of the spread of infectious diseases, but also for causing an unreasonable risk to one's health, failure to undergo the prescribed medical examinations and medical examinations, etc. [2]. An integral system of legal regulation of this area is needed within the framework of the existing legislation in conjunction with a centralized state program to improve medical literacy of the population.

Financing health systems
Sustainability
Sources of financial support in the field of health care are funds from the federal budget, budgets of the constituent entities of the Russian Federation, local budgets, compulsory medical insurance funds, funds of organizations and citizens, funds received from individuals and legal entities, including voluntary donations, and other not prohibited by law sources. At the same time, over the past 10 years, the ratio of public and private sources of funding has remained virtually unchanged: 2/3 and 1/3 of total health spending, respectively [4, 5]. Private sources of funding for the health care system consist of contributions from the population and employers for voluntary medical insurance (6%), as well as personal expenses of citizens for paid medical and sanatorium services (45%) and the purchase of medicines (49%) [6].
At the moment, there is a certain "skew" of government spending on health care depending on the subject of the Russian Federation: higher funding is typical for the central region of Russia and the regions of the Far North. The amount of government funding for health care between the 10 richest and 10 poorest regions differ by almost 2 times [6]. The main problem is the higher economic attractiveness of some regions in comparison with others, which entails a higher level of salaries, and, consequently, a higher volume of tax revenues to the budget. This, in turn, makes it possible to increase the volume of spending on health care, improve the equipment of medical institutions and attract highly qualified personnel, which, in general, leads to an increase in the quality and availability of medical care. At the same time, poorer regions (especially in highly remote and hard-to-reach regions) face an outflow of medical personnel to regions with more competitive salaries. In order to eliminate territorial differentiation, state programs - "Zemsky Doctor" and "Zemsky Feldsher" are being effectively implemented, with the aim of attracting medical specialists to rural areas through financial incentives.
In addition, in order to stimulate the quality of medical care, the FFOMS issued recommendations on the introduction in the constituent entities of the Russian Federation of effective mechanisms for rewarding medical organizations at the expense of the standardized reserve stock of territorial compulsory medical insurance funds. These recommendations provide for the establishment of remuneration depending on the level of accessibility and quality of medical care achieved by medical organizations, as well as the effectiveness of the use of financial resources, measured on the basis of a system of indicators. However, in order to scale this approach, the authors think it expedient to accept the above recommendations of the FFOMS on the remuneration of medical organizations in a mandatory form.
Along with the problem of territorial differentiation, the problem of budgetary funds deficit should be noted. There is a clear understanding that the development of the country's economy is supported by an increase in labor productivity, and ensuring this growth is directly related to the health status of the working-age population, which is assessed by such indicators as temporary and permanent disability, morbidity, and mortality. The demographic changes taking place in Russia pose a threat to the sustainability of the healthcare system in the future. So, for the period from 2012 to 2020, the proportion of people over the age of 65 increased annually, which allows us to conclude that the population is aging and the financial burden on the country's budget is increasing (Table 1).

Thus, the decrease in the working-age population and the resulting increase in the financial burden on the country's budget, as well as comparison with the level of financing of health care systems in developed countries, indicate the need to increase government funding for health care. This is envisaged in all scenarios of health care development (with a conservative forecast under conditions of low rates of economic growth, it is assumed that spending on health care will increase to 6.2% of GDP by 2030; with an innovative one - up to 7.1% of GDP; with a forced one - up to 9.4 % Of GDP) [7].
In our opinion, a number of measures can contribute to solving the problem of the financial deficit:
• Development of PPP. The introduction of private capital into medicine has a wide potential to minimize the dissonance between public funding opportunities and rapidly developing technologies in the medical field, and, in turn, can help improve the quality of medical services and modernize the health care system.
• Assessment of the possibility of providing certain types of medical care on the basis of private medical organizations. This measure will free up budget funds allocated for the construction of state medical organizations.
Of the released funds, it is proposed to use half of the funds to increase the salaries of medical workers, a quarter - to provide the general population (not only beneficiaries) with free medicines on an outpatient basis, and the remaining funds - to improve the qualifications of medical workers, prepare for crisis situations and ensure the work of medical organizations in conditions of increased infectious safety.

Resilience to crises
An example of government support during the COVID-19 pandemic is:
(1) financial support from the reserve fund of the Russian Federation - to provide incentive payments to medical workers providing medical care to patients with a new coronavirus infection, to purchase medical equipment; - Rospotrebnadzor for the provision of subsidies to subordinate organizations in order to ensure the pilot production of medical devices (test systems); - Ministry of Emergency Situations for the deployment of pre-fabricated field hospitals to provide medical care to patients with a new coronavirus infection; - The Ministry of Industry and Trade of Russia to provide measures for the purchase, storage and delivery of personal protective equipment, medical devices and disinfectants with their subsequent transfer at no cost to final recipients, etc .;
(2) amendments to the budgetary list in order to reallocate budgetary allocations for financial support of measures related to the prevention and elimination of the consequences of the spread of coronavirus infection.
However, the main disadvantage of the above mechanism for the redistribution of budgetary funds is time costs. The experience of the pandemic made one think about the creation of a permanent special center for combating epidemics with expanded powers and a separate budget, so that, if necessary, the use of budget funds would be possible without delay. An alternative solution is to create an anti-crisis fund of the Russian Ministry of Health to cover additional costs associated with the epidemic.
In this context, we also think it expedient to provide for a special funding mechanism for organizations whose work is being modified in connection with the need to provide medical care to patients with a new coronavirus infection, which consists in switching from a method of payment for medical care to estimated funding. This measure will increase the resistance of medical organizations to difficult financial situations, which means, in general, will increase the resistance of the health care system to crises.

Medical personnel
Sustainability
2010 to 2019 there is a tendency towards a decrease in the level of provision of doctors and paramedical personnel in Russian state institutions (from 50.1 to 48.7 and from 105.6 to 101.6 per 10,000 population, respectively).
In 2012, a state program was launched aimed at increasing the remuneration of medical workers. From 2013 to 2020, there is an annual increase in the salaries of medical workers, for example, with an increase in the living wage by 56% over the specified period, the salaries of doctors, nurses and nurses increased by 106%, 86%, 174%, respectively (Table 2 ).
A somewhat different situation has developed with the category of junior medical personnel: until 2017, this category is characterized by the same trend as for the rest of the medical personnel. In 2017, we see an almost threefold decrease in the provision of junior medical personnel, which is associated with the approval of the professional standard "Junior medical personnel" in 2016. On the basis of this document, persons who were not involved in the provision of medical care, but were exclusively engaged in cleaning the premises, were excluded from this category (they were transferred to the category of other personnel of a medical organization). In many cases, healthcare organizations have begun hiring outsourcing companies. This measure led to global changes in the staffing of medical institutions. At the same time, the growing indicators of vacant positions and wages suggest that this measure was timely and justified.
The conclusion that the presented changes in the industry are natural and do not indicate an increase in the personnel shortage is confirmed by the dynamics of the turnover rate in the health sector (Table 3). The presented statistics show a significant decrease in the turnover rate of doctors and a slight decrease in the turnover rate of paramedical personnel in 2019 compared to 2015.
Thus, based on the information provided, it can be concluded that a sufficient level of provision of the healthcare sector with medical personnel indicates the stability of the Russian healthcare system. However, on the whole, it seems to us expedient to focus the efforts of the authorities on civic education of the younger generations in the tradition of the prestige of the medical profession and the role of a doctor and a nurse in preserving and strengthening the health of the nation.

Resilience to crises
As a result of the pandemic, many countries, including Russia, faced a labor shortage. However, the mobilization of available resources: the involvement of students, residents and faculty of medical universities, the adaptation of hospital premises for infectious diseases and the rapid construction of new hospitals, training of personnel and an increase in the duration of work shifts, made it possible to take the situation under control. The conclusion from this situation was the beginning of work on the creation of a system for countering pandemics and other emergencies, which consists in creating an algorithm for re-profiling individual medical organizations (from specialized activities to infectious ones) [8].
The pandemic revealed that capacities can be urgently increased and personnel redistributed. The issue of education cannot be resolved so quickly: the demonstrated lack of doctors' skills in triage of incoming patients, the use of personal protective equipment, and reasonable vigilance indicates the need to supplement or revise ongoing educational courses and refresher courses on infectious diseases.
In order to ensure the safety of medical workers, there are regularly updated guidelines and safety instructions, including instructions for the use of PPE; hospitals are divided into "dirty", "clean" and "transitional" zones; hospitals are provided with PPE, antiseptics, air disinfectants, and ultraviolet irradiators. For psychological support of medical personnel, hotlines for psychological assistance have been organized, recommendations for psychological support have been developed for medical personnel working with coronavirus. In addition, free accommodation for all health workers of infectious diseases wards in hotels and hostels is offered to eliminate their fears of infecting their loved ones. In addition to the above measures, the authors propose the provision of medical creams and ointments for the treatment and prevention of eczema and other skin diseases caused by prolonged wearing of PPE to medical workers free of charge.

Medicines and technologies
Sustainability
Assessment of technologies in healthcare, including medicines, medical devices, procedures and organizational systems, is actively used in Russia as a tool for shaping healthcare policy and implies a comprehensive study of the medical, social and economic efficiency of methods for maintaining and restoring health. The mechanisms available in the arsenal of economic evaluation allow comparing according to several selected criteria and choosing the most effective alternative. At the same time, in the legislation of the Russian Federation there is no clear fixation of the threshold values ​​of economic efficiency.
In this regard, the authors raise the question of the need for unification and legislative consolidation of indicators of threshold values ​​of economic efficiency, for example, the cost of acquired years of quality life or the price of one year of saved life, adjusted for impaired functional ability. On the one hand, this increases the consistency and transparency of the management decision-making process. On the other hand, often the need to make decisions based on a single factor deprives the management apparatus of a certain flexibility and does not allow taking into account other factors besides the economic one. In addition, for different nosologies, diseases and time periods in the development of the state, indicators of threshold values ​​of economic efficiency can be very different. Thus, it seems to us advisable to introduce a flexible system of threshold values ​​of economic efficiency, subject to periodic revision to objectively reflect the economic situation in the country, and taking into account the possibility and mechanisms of using promising medical technologies that are economically ineffective, for example, by introducing copayments; highlighting diseases or patient groups that should be financed in the first place, etc.
In the Russian healthcare system, in order to support the introduction and development of high-cost new technologies in medical institutions, within the framework of the federal budget, funding is provided for high-tech medical care and medical care provided as part of the clinical testing of methods of prevention, diagnosis, treatment and rehabilitation. In 2019, funding for the project accounted for 23.8% of the total federal budget spending on the health care system. In 2020, funding for the project increased by 10.7% compared to 2019, and in 2021 an increase of 2.1% is foreseen. At the same time, the authorities often provide for additional targeted funding in priority areas of development of the health care system, for example, for equipping budgetary institutions with telemedicine equipment.
In general, the achievement of "digital maturity" of the healthcare system is enshrined at the legislative level as one of the main national development goals of the Russian Federation for the period up to 2030. As a result, the share of mass socially significant services available in electronic form should increase to 95% [9].

Since 2019, the technological transformation of healthcare has been carried out in accordance with the national project "Healthcare", in which the list of main directions includes the creation of a single digital circuit and the introduction of innovative technologies (10% of the total funding of the national project). In accordance with this project, by 2024 the number of citizens who constantly use electronic medical information systems should increase more than 1000 times and cover a quarter of the population of the Russian Federation. And by 2022, all medical organizations in the country, regardless of their form of ownership, should switch to the use of medical information systems, as well as integrate into the Unified State Information System in the Healthcare Sector (YGISZ) - a national information system created to provide effective information support to bodies and organizations of the health care system. , as well as citizens in the framework of the management of medical care and its direct receipt. Currently, the volume of accumulated information in the Unified State Health Information System is more than 1.2 billion cases of records, the following components have been put into operation and are actively used: an electronic registry, a management accounting system for administrative and economic activities, a medical information system of a medical organization, as well as a federal integrated electronic medical map.
However, in this context, such a threat to the stability of the Russian healthcare system should be noted as a lack of open data, including data integrated into registers. In Russia, such federal registers exist only for certain diseases, such as diabetes mellitus, orphan diseases, neoplasms (in addition to the above-mentioned COVID-19 register). The creation of federal registers for all nosologies will allow collecting detailed information about various diseases, analyzing it and identifying patterns, as well as tracking the real effectiveness of measures taken, which, ultimately, will improve the quality of management decisions in the industry. In addition, these registers will largely contribute to the creation of a high-quality non-biased source of professional knowledge (possibly at a supranational level) - a system that allows you to obtain reference information on differential diagnosis and treatment.
We also see one of the most important areas of development in the "closure" of a single information circuit, which was discussed above. This means obtaining the result of work on a federal project in the form of complete mutual integration of electronic medical systems at all levels, as a result of which the continuity of patient treatment in any institution of the country will be ensured, as well as a powerful analytical and statistical tool will be formed.
The boom of telemedicine in Russia began even before the coronavirus pandemic: in 2019, 679 thousand telemedicine consultations (consultations) were held, of which 85% were in the "doctor-patient" format. Compared to 2018, the number of online consultations has doubled. In 2020, the demand for remote consultations of doctors grew by 177% compared to the same period in 2019 [9]. However, despite the observed boom of telemedicine, the territory of the Russian Federation is still far from 100% coverage by telemedicine services. This is partly due to the fact that only a number of pilot regions have now included remote consultations in the basic MHI program. In addition, the following basic regulatory gaps are inhibiting the development of telemedicine:
• ambiguous approach to remote diagnosis;
• the absence of legislatively enshrined norms that establish the stages of providing medical care using telemedicine technologies, structural units that provide such assistance, standards for providing medical care using telemedicine technologies that would determine the minimum equipment for a "virtual doctor's office", the goals of its activities;
• insufficient level of reliability of patient identification in some cases;
• the presence of risks of leakage of personal data of patients and violation of the medical secrecy regime by providing this information to third parties;
• weak regulation of cybersecurity and the lack of a clearly structured system of penalties for cybercrimes, etc.

For example, according to a sociological survey conducted by NIIOZMM DZM in 2019, 19% of doctors noted that they work with personal data in accordance with regulatory documents, 52% of doctors have an understanding at the level of personal experience and common sense, and 3% do not have ideas about working with personal data [10].
The main recommendation of the authors for strengthening the sustainability of the health care system in terms of supporting the development of telemedicine technologies and ensuring equal access to them throughout the country is to improve the existing regulatory framework.
In addition, we see it as expedient to increase the information culture of doctors and patients. According to the above sociological survey, 32% of doctors would like to attend educational courses in order to improve their knowledge [10]. Speaking about digital literacy of the population, only 24% of respondents believe that they know what telemedicine is [11]. Overall, 53% of Russians find it difficult to master digital technologies. To solve this problem, free courses to increase the level of digital literacy of the population are functioning on an ongoing basis in many large cities of Russia. Note that increasing digital literacy is one of the two main areas of struggle against the problem of eliminating the digital divide.
The second direction of the struggle is the development of communication infrastructure, carried out in accordance with the centralized federal program, as a result of which, as of 2020, all cities of Russia are provided with a stable Internet, 88% of settlements with a population of 500 to 10 thousand people and 57% - with with a population of 250 to 500 people. A further direction of the project's development is to provide Internet access to all settlements with a population of 100 people and to increase the speed of the Internet connection to 10 Mbit / s, as well as legislative consolidation of the principle of non-discriminatory connection to access points.
Thus, for the further development of this direction of actions of the authorities, the authors propose the introduction at the federal level of a program to improve the information culture of the population, which obliges the regional and municipal authorities to open free courses to improve computer literacy, and, if necessary, create Internet clubs in which anyone can use a computer to access the Internet.
In the context of this section, I would also like to note that in accordance with the amendments made to the Constitution, the knowledge-intensive industry, including IT-technologies, medicine and research activities, has become one of the priority areas of funding along with social support.
New mechanisms of state support for the medical and pharmaceutical industry provide for financial support of manufacturers' costs for the implementation of projects, from the R&D stage and clinical trials / trials to the introduction of the development into industrial production; determination of the recipients of the subsidy through competitive procedures; establishing indicators of the effectiveness of project implementation. This is a very important step in creating a competitive science funding scheme. In addition, state medical institutions were advised to purchase medical products and equipment from domestic manufacturers with similar technological characteristics.
Thus, a course has been taken to protect, support and develop domestic production, which at the same time do not limit the possibilities of technology transfer, stimulate the localization of foreign production and the development of projects with the attraction of foreign investment.
At the same time, it seems to us expedient to create a separate Fund for the Health of the Nation, using the model of the Russian Foundation for Basic Research. Separate funding will allow, through grants, to strengthen medical research at universities and academic institutions throughout the country, supporting the best scientists in them, and improving them organizationally and structurally.

Resilience to crises
In a planned manner in Russia, standards are drawn up annually for stocks of medicines, PPE, beds and medical equipment in case of an influenza pandemic. In 2020, when a pandemic of a new coronavirus infection was announced in the world, a table was compiled comparing these norms with the norms of stocks when a coronavirus pandemic appeared. At the same time, at the beginning of the period of the spread of coronavirus infection, Russia faced the lack of the necessary volumes on the market. As a reaction to the current situation at the federal level, they temporarily simplified the procedure for admitting PPE to the market, customers began to buy goods and services without a competition, and most manufacturers increased production by 20-50%. Currently, the capacities of industrial enterprises make it possible to satisfy requests in all means that are used in the provision of assistance, prevention and treatment of coronavirus.
Nevertheless, in our opinion, the existing measures to control the price level of PPE and drugs are not efficient enough. It is necessary to take legislative measures to limit for a certain period of mediation in relation to certain groups of goods necessary to treat and prevent the spread of COVID-19. At the same time, it is necessary to strengthen the work of the FAS, as well as law enforcement agencies, aimed at preventing speculation in this area. However, excessive regulation of prices should not be allowed, the inevitable consequence of which may be the appearance of a deficit.

Organization and provision of health care
Sustainability
The quality of the provided medical care is one of the criteria contributing to the reduction of the length of stay of the patient in the hospital bed. Moreover, we are talking not only about high-quality treatment in hospitals, but also about the provision of quality medical services in outpatient facilities, since one of the reasons for the long stay of patients in beds is insufficient examination and treatment in polyclinics. Improving the continuity between outpatient clinics and hospitals also shortens the length of time patients stay in bed. The statistics presented in Table 4 over the past decade indicate an annual reduction in the length of stay of a patient in a hospital bed (by 16% in 2019 compared to 2010).
The improvement in the quality of outpatient care and the continuity of care between levels is partly due to the popularization of the general practitioner profession. A general practitioner differs from a local doctor by deeper knowledge and skills in various fields of medicine. The main tasks of a general practitioner are: prevention, diagnosis and treatment of the most common diseases; provision of emergency and urgent medical care; performing medical procedures, as well as dispensary observation of chronic patients. Whereas the district doctor mainly issues referrals to narrow specialists and sick leaves. Both are primary care specialists. The specialty of a general practitioner is more in demand in rural areas due to the economic inefficiency of the construction of medical and preventive institutions in each locality. In Moscow, in order to popularize the profession of a general practitioner, such specialists have a monthly incentive pay supplement; educational work is carried out with the population about the possibility of contacting such a specialist in a polyclinic. Thus, the general practitioner can contribute to improving the continuity of treatment between levels of care by supervising the patients assigned to him.
At present, the main focus of the existing healthcare system in Russia is focused on the inpatient and ambulance segment, while prevention, early diagnosis, the rehabilitation system and palliative care are underdeveloped, which ultimately leads to a significant increase in the burden on healthcare resources. For example, rehabilitation beds make up only 2% of the bed capacity.
To eliminate the above bias, the prevention of diseases is included in the number of the main tasks stipulated by the Strategy for Healthcare Development until 2025. In 2020, the Strategy for the formation of a healthy lifestyle for the population, the prevention and control of non-communicable diseases for the period up to 2025 (hereinafter - the Strategy for a healthy lifestyle) was also approved. It pays special attention to the prevention and control of such diseases as: cardiovascular diseases, malignant neoplasms, chronic respiratory diseases and diabetes mellitus.
In accordance with the established targets, by 2024 (compared to 2017) it is planned to reduce mortality from diseases of the circulatory system by 23.4% (including the hospital mortality rate from myocardial infarction from 13.2% to 8%), from neoplasms - by 7.8%, and in general the mortality rate of the working-age population - by 27.8%. In addition, it is planned to double the coverage of citizens with preventive medical examinations. Currently, as a result of the policy of mass preventive medical examinations and clinical examination of the population, the proportion of early detection of malignant neoplasms has already increased (56.4% in the first and second stages), which has led to a decrease in one-year mortality rate to 22.2% and an increase in five-year survival rate to 54. four%. In general, according to a sociological survey conducted by NIIOZMM DZM in 2020, 66% of respondents underwent medical examination or preventive medical examination over the past 2 years [12].

However, in spite of the fact that preventive medicine in Russia is not inferior in quality and accessibility to any other type of medical care, in the public consciousness it still remains one of the most underestimated types of medical care. The main reason for respondents' appeal to the polyclinic is the presence of complaints, but not a preventive examination. According to a sociological survey conducted by NIIOZMM DZM in 2020, only 31% of respondents visit doctors on time [12]. Therefore, we see the direction of the main focus of policy in this area on overcoming the crisis of social consciousness and further promotion of health-preserving practices.
In addition, as an option for solving the problem of overloading the segments of inpatient and emergency care, it is proposed to introduce daily rehabilitation on a strong base of hospitals, as well as to develop institutions of treatment and care at home with the provision of narcotic analgesics to all patients who need them (in order to prevent the abuse of emergency ambulance: it can call in order to measure pressure or give an injection).

Resilience to crises
During the first wave, in order to protect public health and prevent the spread of a new coronavirus infection, the All-Russian medical examination of the population was temporarily suspended, as well as preventive medical examinations (except for some population groups, for example, for those working at height). In addition, hospitals redesigned for infectious diseases canceled hospitalizations and planned operations for other patients. Many non-urgent planned surgeries, including plastic surgeries, have been postponed so as not to overload the system due to the spread of the coronavirus. At the same time, oncological care, chemotherapy, radiation therapy, hemodialysis and a number of other types of medical care were provided as usual.
At the same time, all measures were taken to increase the capacity of hospitals to receive coronavirus patients. First, the hospitals that should receive patients with COVID-19 were identified, and they were re-profiled (or a number of hospital departments were re-profiled). Secondly, home hospitalization of patients with mild to moderate severity of COVID-19 began to be practiced, and a number of medical services began to be provided using telemedicine, for example, monitoring the condition of patients. Finally, potentially suitable non-medical facilities were redesigned as hospitals for patients with coronavirus infection, and temporary medical posts (for example, field hospitals) were created.
It should be noted that in the context of the provision of medical services, the Russian health care system has demonstrated a high level of resilience to the pandemic. The only direction in which we could recommend improvement is the expansion of the network of medical outpatient clinics (feldsher-obstetric stations, paramedic health posts) and the revision of the standards for their equipment (air preparation system, modern conditions for isolating infectious patients, etc.), in order to so that they can eventually become networked hubs to fight possible future infections and epidemics.

Conclusion
The synthesis and analysis of materials relevant to the study of the impact of the coronavirus infection pandemic on the Russian healthcare system, supplemented by expert assessments of the situation and examples from practice, made it possible to present a set of recommendations aimed at strengthening the resilience of the healthcare sector and resilience to crises.
Thus, the first direction of increasing the stability and resistance to crises of the Russian health care system is the issue of strengthening the existing regulatory legal framework in terms of adapting to the current crisis and preparing for potential crises of various kinds in the future. These recommendations are confirmed by the fact that the Russian legislative system as a whole is characterized by a high degree of elaboration of various norms and in an emergency situation it is unusual and often difficult for all parties involved to function without proper regulation of their actions. The considered context allows us to speak of the need to remove legal barriers to the development of technologies, improve the legal framework in terms of the provision of telemedicine services and cybersecurity, strengthen control over certain groups of goods necessary to treat and prevent the spread of COVID-19, in terms of temporary restrictions on mediation in relation to these goods and strengthening the work of the FAS and law enforcement agencies in order to monitor compliance with these measures.
Secondly, an increase in funding for the industry is a fundamental measure that contributes to strengthening the resilience and resilience of the health care system in this direction. Additional budgetary funds aimed at developing the healthcare sector can be used, inter alia, to prepare for crisis situations and ensure the work of medical organizations in conditions of increased infectious safety. This measure will be especially effective if for its implementation a separate fund is created to compensate for the costs of combating epidemics, and a mechanism for the estimated financing of medical organizations in crisis situations is provided. In addition, to increase the transparency of the management decision-making process and support the implementation and use of health technologies, it is proposed to create a flexible system of threshold values ​​for economic efficiency, as well as a separate National Health Fund, focusing exclusively on health problems.

Thirdly, among the organizational and managerial measures to maintain and enhance the stability and resistance of the Russian healthcare sector, we can include the maximum assistance to the process of digitalization of the healthcare sector, since at present it represents a logical and uncontested stage in the evolution of human development. This assistance includes, among other things, completing the process of closing a single digital circuit, which consists in the complete mutual integration of all electronic medical systems and eliminating the lack of open data. In addition, the issue of reducing the burden on the segments of inpatient and emergency care by redistributing it to segments of preventive and rehabilitative care remains on the agenda. To achieve this goal, it is proposed to introduce daily rehabilitation on a strong base of hospitals and to develop institutions for treatment and home care. Finally, the authors recommend the development of a network of medical outpatient clinics so that they can serve as an intermediary in isolating the sick during the outbreak of future infections and epidemics.
The last group of measures to strengthen the resilience of the health care system and its resilience to crises include a variety of public and social activities, for example, raising the information culture of the population or promoting health-saving practices, including with the aim of involving the population in receiving preventive health services. In addition, the authors consider it advisable to expand the educational program of medical workers on infectious diseases in terms of preparing for epidemics, as well as the creation of short educational courses on the risks and counteraction of epidemics for the general population, similar to the first aid courses. Finally, an important focus of state policy should be to increase the prestige of the doctor's profession by increasing the competitiveness of salaries of medical workers, providing conditions for career growth with the establishment of additional benefits for seniority and / or high performance indicators, shaping the image of the profession, etc. The result will be increased competition for workers places, improving the quality of provided medical services, reducing the threat of staff drain, which in general will make the health care system more stable.
The list of proposed measures is not exhaustive. Moreover, the dynamics of the development of the situation presupposes further study of the issue. In this regard, the team of NIIOZMM DZM plans to continue monitoring the Russian health care system, and the team of the London School of Economics plans further work to develop and improve the created framework by attracting more participating countries in order to exchange the results obtained in 2 years and conduct analysis of changes in order to identify the main trends in the development of the sustainability of the health care system and its resilience to crises.

About the authors

Elena I. Aksenova

Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department

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

PhD in Economics

Russian Federation, 9, Sharikopodshipnikovskaya str., 115088, Moscow

George Wharton

London School of Economics and Political Science

Email: G.A.Wharton@lse.ac.uk

Senior Lecturer

United Kingdom, London

Nadezhda A. Vosheva

Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department

Email: VoshevaNA@zdrav.mos.ru
ORCID iD: 0000-0001-6546-3530
SPIN-code: 8004-8530

Head of the Sector

Russian Federation, Moscow

Dan Gocke

London School of Economics and Political Science

Email: d.j.gocke@lse.ac.uk

Research Associate

United Kingdom, London

Natalya N. Kamynina

Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department; Institute of Social and Economic Studies of Population of Russian Academy of Sciences

Author for correspondence.
Email: KamyninaNN@zdrav.mos.ru
ORCID iD: 0000-0002-0925-5822
SPIN-code: 2031-6825

MD, PhD

Russian Federation, 9 Sharikopodshipnikovskaya street, 115088 Moscow

References

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