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0DOI: 10.29141/2658-5081-2023-24-1-6 EDN: VJTWFU JEL classification: I10
Mikhail A. Safarov OOO "Polymedika", Chelyabinsk, Russia
Quality of accessibility vs quality accessibility of medical service in Russia: Measurement issues
Abstract. One element of human capital that determines the prospects of national economic growth is population health. This is a multivariate concept and therefore, there can be distortions in estimating its level depending on the chosen metrics. The efficiency of the health care system as an indirect indicator of a nation's health is often measured through composite indicators of the medical service quality and accessibility. Nonetheless, in the conditions of limited resources such evaluation may not reflect the actual situation. The paper aims to discuss the problems related to the balance in the quality and accessibility of medical service in Russia. Methodologically, the research relies on classical macroeconomics. The method is the analysis of series of socioeconomic indicators collected from Russian statistics for 2012-2021. The findings point to the existence of a normative and positive approaches to measuring the efficiency of the health care system based on the composite evaluation of the two parameters: the medical service quality and accessibility. The authors prove that such methodological ideology is erroneous, and suggest evaluating relative indicators that illustrate the ratio between the two parameters. The case of one of such ratios - a relative evaluation of the number of physicians, hospital beds and diseases per group -allowed obtaining the assessment of the labour productivity. According to the conclusions, the accessibility of the medical service in Russia is decreasing, which however, does not lead to the improvement of its quality.
Keywords: health economics; human capital; quality of medical care; accessibility of medical care; health care efficiency.
For citation: Safarov M. A. (2023). Quality of accessibility vs quality accessibility of medical service in Russia: Measurement issues. Journal of New Economy, vol. 24, no.
1, pp. 126-141. DOI: 10.29141/2658-5081-2023-24-1-6. EDN: VJTWFU. Article info: received October 11, 2022; received in revised form November 22, 2022; accepted December 1, 2022
Introduction
National health care systems are greatly challenged by rising costs of providing medical care to the population. This growth is due to a number of reasons: increase in the number of citizens over the working age with a simultaneous decrease in the birth rate, problems with finding and retaining qualified medical personnel, development of medical technologies and the corresponding upturn in their cost, the tense epidemiological situation due to the COVID-19 pandemic, etc.
At the same time, rising costs do not directly influence the efficiency, which means using the resources in ways that optimise desired outcomes. Reportedly, 20-40 % of health care expenditures are wasted1. Hence, a more rational allocation of available resources is one of the major strategies ensuring a nation's health.
The general equilibrium theory by Hicks and Arrow [Hicks, 1939; Arrow, 1985] postulates that the economic system is maximally efficient when the allocation of resources is such it permits to increase the production of one product only by reducing the production of the other. To reiterate, in conditions of limited resources, additional production is associated with opportunity costs consisting in rejecting the production of another product. This idea can be extrapolated to consideration of how correct are the approaches to allocating the costs of providing medical services, the substantial part of which is a public good.
The social justice perspective implies equal (and therefore, free of charge) access of citizens to basic medical services. Consequently, "a medical service vividly expresses the nature of social relations, but violates the law of cost" [Badaev, Veretennikova, 2009, p. 10]. This means the active state's interference into market relations, and hence, causes its 'failures'. The signs of low efficiency of the state as a regulator include a deficit in the distributed product and/or its low quality. Thus, medical services due to being a public good have properties, which impede settling the problem of their efficient distribution in terms of quality or quantity (accessibility).
Federal law of November 21, 2011 no. 323-FZ (as amended on December 28, 2022) "On the basics of protecting the health of citizens in the Russian Federation" also does not take into account that improving the quality of health care can destabilise the indicators of its accessibility (quantity), and vice versa. Even an increase in budget financing can lead to an imbalance between these parameters.
Article 10 of this law proclaims the following obligations of the state regarding the availability of medical care:
• provision of medical care on the principle of proximity to the place of residence, place of work or education (paragraph 1);
1 World Health Organization. (2010). The World Health Report 2010. Health systems financing: The path to universal coverage. https://www.who.int/publications/i/item/9789241564021.
• availability of the required number of medical workers (paragraph 2);
• guarantee of a certain volume of medical care (paragraph 5);
• accessibility of health facilities (by transport and digital means) (paragraphs 7, 8, 10).
This law defines the concept "quality of medical care" as "a set of characteristics
reflecting the timeliness of providing medical care, the correct choice of methods of prevention, diagnosis, treatment and rehabilitation during medical care, the degree of achievement of the planned result" (paragraph 21 of Article 2). The parameters of the quality of health care include the presence of medical workers of a certain level of qualification (paragraph 2 of Article 10), the establishment of medical care standards (paragraph 4 of Article 10), as well as the provision of health facilities with equipment (paragraph 9 of Article 10).
Such "frame" formulations allow one to quite freely interpret the possible ways to achieve the target efficiency of medical care. Russian health care, which is based on the Soviet system, has always focused primarily on the parameters of its accessibility. At the same time, the American health care system that merged with voluntary health insurance, guarantees just minimum medical care, but develops towards the quality of services. What's more, in accordance with the economic viewpoint, there exists the concept of 'excessive' quality of medical care (including 'excessive' reduction in mortality). It means that if the additional unit of quality improvement is small, then it makes sense to invest in assets that increase the availability of medical care [Gaynor, 2006].
The purpose of the study is to identify the existing balance in the Russian health care system between indicators of accessibility and quality of medical care. In the course of the work, we took into account that the COVID-19 pandemic also could have become a trigger for changing the proportions in favour of one or another group of indicators.
Hypothetically, the health care system has four options for the development: an increase in the indicators of accessibility and quality of medical care or their deterioration; restructuring of this system in favour of either the quality or accessibility of medical care. Accordingly, the objectives of the study are to investigate the existing metrics for assessing the accessibility and quality of medical care, to determine our own methodological approach to this assessment, as well as to test it empirically.
Evaluating the efficiency of the health care system: Approaches to determining the parameters of quality and accessibility
of medical care
The health care sector is characterised by three types of efficiency: medical, social and economic [Nazarova, Borisenkova, 2017, pp. 120-121]. Under medical efficiency we understand the achievement of a certain result in the field of public health, the social
one is the degree of satisfaction of citizens with the quality and accessibility of medical care, and economic one is a direct or indirect impact of public health indicators on macroeconomic indicators.
The issue of balancing these types of efficiency is not trivial in itself (cf. [Jacobs, Smith, Street, 2006; Hollingsworth, 2013]). We believe that these types of efficiency can be defined using process, resource and resulting groups of indicators. The logic of assessing the level of the health care system efficiency is visualised in Figure.
However, as shown below, in the existing body of literature there is a significant fragmentation and, at the same time, redundancy and confusion when using these groups of indicators for analysis. In this regard, an intermediate objective of our research is to establish the adequacy of using the metrics of medical care availability and quality in the health care system.
We can distinguish between two approaches to studying the problems of health care, including the problems of evaluating the accessibility and quality of medical care.
The normative approach uses statutory assessments and target indicators. With the medical services provision being highly regulated and interactions between actors in the health care system being of the quasi-market nature, this approach has become quite frequently used in practice.
We already noted that the basic principles for the functioning of the health care system in Russia are laid down by the Federal law of November 21, 2011 no. 323-FZ "On the basics of protecting the health of citizens in the Russian Federation". The priorities in this area are established by the State programme of the Russian Federation "Health care development"1, which targets the improvement of mortality indicators. This state programme incorporates the national project "Health care", which outlines avenues for achieving these target indicators within the framework of 8 federal projects: by developing a system for providing primary health care; by fighting against cardiovascular and oncological diseases; by developing children's health care and providing health facilities with personnel; by introducing innovative medical technologies and a unified information system, etc. In addition, the project part of the state programme includes 2 federal projects implemented within the national project "Demography": "Strengthening public health" and "Elderly generation". In total, 10 federal projects also use indicators of the medical care quality and accessibility.
Since 2013, Russia has introduced an independent system for assessing the quality of operation of organisations providing social services, including medical ones2. This system focuses on evaluation of the openness and availability of information about an
1 On approval of the state programme of the Russian Federation "Health care development": Decree of the Government of the Russian Federation of December 26, 2017 no. 1640. (In Russ.)
2 On the formation of an independent system for assessing the quality of operation of organisations providing social services: Decree of the Government of the Russian Federation of March 30, 2013 no. 286. (In Russ.)
Algorithm for determining the health care system efficiency
organisation; comfort conditions and availability of services; health service waiting time; friendliness and competence of employees. These criteria are measured by the corresponding indicators approved by the Ministry of Health of the Russian Federation for medical institutions participating in the Programme of state guarantees of providing free medical care to citizens1.
The positive approach implies an objective research-based assessment of a particular problem. In this case, the obtained results do not have to correspond to the targets set by the state and are of interest in themselves.
It is noteworthy that in practice, the use of statistical data in its pure form reduces the objectivity of the analysis even within the framework of a positive approach to research. For example, the Independent Monitoring Foundation "Health" [Gavrilov, Shevchenko, 2016] assesses how the regions of Russia are fulfilling their own planned values for reducing mortality and ensuring sufficiency with medical personnel.
The health systems efficiency ranking proposed by Ulumbekova, Ginoyan and Kalashnikova [2017] is an attempt to link the resulting indicators of health care efficiency (life expectancy) with the growth of economic metrics (gross regional product per capita, public health financing per capita, sales of spirits per capita).
The authors of another ranking [Yashina et al., 2018] suggest calculating 24 indicators from the reports of Russian state authorities to evaluate the efficiency of public health financing in a region, which reflect: 1) health care expenditures, including the level of budgetary funding and funds from the Federal Fund for Compulsory Medical Insurance (FFCMI), and also the level of remuneration of medical personnel; 2) the level of social effect produced by the health care system; 3) the density of the network of health facilities and the intensity of its use, including the degree of workload of medical personnel, the intensity of the use of hospital beds and the provision of emergency medical care. The suggested approach, therefore, brings together the process and resource groups of health care system efficiency metrics.
Experts of the Financial University under the Government of the Russian Federation measure the level of medical service in Russia's largest cities by combining the data of the resulting indicators (a ratio between the annual number of deaths to the population over the working age and the degree of patient satisfaction with various characteristics of medical services according to the results of a sociological survey). They also account for the financial burden on household budgets when there is a need for paid medical services2. However, this assessment does not distinguish between the
1 On the approval of indicators characterising the general criteria for evaluating the quality of the conditions for the provision of services by medical institutions which are subject to an independent assessment: Order of the Ministry of Health of the Russian Federation of May 4, 2018 no. 201n. (In Russ.)
2 Leaders by the quality of health care - Moscow, Saint Petersburg, Surgut, Balashikha and Tyumen. (2018). http:// www.fa.ru/science/index/SiteAssets/Pages/Zubets_Pubs/69_Med_Quality_2018.pdf. (In Russ.)
indicators of the quality and accessibility of medical care, and there are inaccuracies in the integration of indicators.
Of interest is the logic behind the ranking presented by McKinsey&Company together with the U.S. News & World Report magazine1. It implies assessing a wide range of objective indicators, including the access to health care services (according to the authors of the ranking, this is the number of visits to doctors and coverage with health insurance); the quality of medical care (in particular, the hospital readmission rate), and a much broader compared to Russia list of resulting "state of public health" metrics: levels of mortality, obesity, smoking prevalence, suicide and mental health.
The health care accessibility and quality ranking was also composed as part of the Global Burden of Disease Study for 195 countries [Barber et al., 2017]. It utilises the indicators of mortality that can be prevented if quality and timely medical care is provided.
The Conference Board of Canada2, an analytical centre, ranked Canada's territories according to several groups of indicators. Health indicators were assessed based on the mortality rate of various population groups. Further, this study was supplemented by the study of indicators of the resource base for the provision of medical care3.
One of the most comprehensive approaches to measuring the efficiency of health care systems is pursued in the Euro Health Consumer Index created based on the data from 35 countries by the Health Consumer Powerhouse Ltd4. The ranking is interesting in that the list of common process indicators contains the "patient rights" metrics, particularly the following:
• existence of specialised patient organisations and their involvement in decision-making;
• the right to a second opinion without additional payment for a visit to a physician;
• patients' access to their medical history;
• availability of a register of conscientious physicians;
• the possibility of receiving medical care outside your country, which is financed by this country under the EU agreement;
• availability of a national directory of medical care providers with a quality rating for patients.
Shishkin et al. [2019] propose measuring the differentiation of medical services across the regions of the Russian Federation using 56 indicators presented in the
1 Best states 2018: How they were ranked. https://www.usnews.com/media/best-states/overall-rankings-2018.pdf.
2 Provincial and Territorial Ranking. Health. 2015 (2019). https://www. conferenceboard.ca/hcp/provincial/ health.aspx.
3 A resource for Canadian health professional organizations and their membership. https://www.canada.ca/ en/public-health/services/publications/healthy-living/communicating-about-substance-use-compassionate-safe-non-stigmatizing-ways-2019.html.
4 Health Consumer Powerhouse. (2018). Euro Health Consumer Index 2018 Report. https://healthpowerhouse. com/media/EHCI-2018/EHCI-2018-report.pdf
materials of state and industry statistics. These indicators are lifespan and mortality, provision of health facilities with equipment and buildings, information and medicines supply, staffing, complex types of treatment, etc. However, firstly, the ranking creators also try to provide an aggregated assessment of the resulting, process and resource indicators. Secondly, the objectivity of the study is distorted by its normative goal-setting. As noted by the authors themselves, "the choice of these particular groups of indicators corresponds to the priority areas for the development of the health care system defined in the national project "Health care" (2019-2024) and the State programme of the Russian Federation "Health care development" (2018-2025)" [Shishkin et al., 2019, p. 16].
Experts of the National Research Centre for Therapy and Preventive Medicine of the Ministry of Health of the Russian Federation have developed a method for a comprehensive quantitative assessment of the efficiency and quality of medical care provided in the constituent entities of the Russian Federation1. In accordance with the principle of accessibility, it covers the indicators from the national project "Health care", namely standardised (total mortality and mortality of the working-age population) and non-standardised ones (providing population with screening programmes and detecting chronic non-communicable diseases in the course of population screening).
The research by Voskolovich [2021], based on statistical and sociological data, analyses the issues of household satisfaction with the quality and accessibility of medical services, the opportunity of having remote medical consultations, and the affordability of paid medical services. The study identified the key problems in the field of medical care quality: dissatisfaction with the work of district physicians, a shortage of medical specialists, and a long wait for an appointment. Thus, in this contribution, the accessibility metrics are not separated from the metrics of medical care quality as well.
Nazarova and Borisenkova [2017] attempted to correlate the resulting and process indicators of medical care in Russia, that is, to assess the efficiency of the health care system. Using the data from 11 countries for 2000-2013, they proved a direct dependence of the population lifespan on income inequality measured by the Gini coefficient, and an inverse dependence on the average per capita income and the share of government spending on health care in total government spending. The method used involved calculating the production function of health, which makes it possible to assess how the irrational use of resources affects various health indicators of the population.
The presented array of research exhibits a number of methodological shortcomings._
1 Ranking of the constituent entities of the Russian Federation in terms of the efficiency and quality of medical care in accordance with the criteria proposed by the Federal State Budgetary Institution "National Medical Research Center for Therapy and Preventive Medicine of the Ministry of Health of the Russian Federation". https:// org.gnicpm.ru/rejting-subektov. (In Russ.)
First, the developed rankings concentrate on creating relevant mathematical tools to aggregate the existing indicators, which affects the correctness with which the ranks of the studied territories are distributed. However, in most cases the adequacy and comparability of these indicators are not assessed. This conclusion is indirectly confirmed by the fact that the same weight coefficients are used during aggregation.
Second, within the framework of the proposed approaches, the calculations are often tilted towards a particular direction, such as analysing the accessibility or quality, the result or the process of medical care. In other words, ranking allows one to offset the weaknesses of one group of indicators at the expense of the strengths of another group. For example, a rise in the number of hospital beds does not indicate an improvement in medical care, but it can significantly increase the formal assessment of the health care system efficiency.
Third, if a number of researchers differentiate between the groups "result - resources" or "result - process", then the indicators of quality and accessibility are mercilessly mixed. Such an inaccuracy is, in our opinion, unacceptable (and motivates to conduct the current research) and leads to the fact that the integral assessment applied in most rankings is not very informative.
Fourth, the proposed methods, despite the data compilation, are based on the indicators' absolute values presented in the statistics, and therefore are tied to the target values of government programmes. This allows concluding that the studies under review are written in a normative but not a positive sense.
And, fifth, the very indicators require a more in-depth comprehension. Let us dwell on this issue in more detail.
What the health system statistics say: Measuring problems
Researchers note that differences in widely used mortality rates and subjective assessments by citizens of their state of health depend not only on the real conditions for receiving high-quality medical care, but also on a number of non-medical factors [Shishkin et al., 2019, p. 17], including such ambiguous ones as seasonality [Kuznetsova, Maleva, 2022] or parents' financial resources [Kartseva, Kuznetsova, 2021]. Having systematised 131 studies published between 2000-2021, Mbau et al. [2022] found that the efficiency of the health care system depends on the demographic and socioeconomic characteristics of the population, its health level and well-being, macroeconomic, managerial and political features of national and subnational regions, as well as on the properties of the system itself. The COVID-19 pandemic has also distorted the institutional logic of this system [Orekhova, Safarov, 2022]. A number of studies [Javed et al., 2020; Alzueta et al., 2021; Cherkashin, Krasnoshtanova, 2022] examined the diversity of population responses to the pandemic depending on temporal and spatial circumstances.
The foregoing signifies that the issues of accessibility and quality of medical care require an individual meaningful reflection.
Accessibility indicators are most often interpreted as spatial (including transport and infrastructure) and physical proximity to health facilities and are measured as the number of health facilities per 10,000 people. Some researchers (cf. [Xiong et al., 2022]) applied network analysis methods to estimate the geographic density of primary medical care. At the same time, since the strengthening of the medical services technological level leads to a natural enlargement and concentration of medical care stations within single medical centres [Sheyman, 2007, p. 40], the dynamics of estimated hospital beds numbers serves as a more relevant indicator of the medical care accessibility. However, there are various possible interpretations of this indicator. For example, some national health systems provide little or no inpatient care, and in these countries the patient is admitted to hospital only in cases of emergency.
One of the dominant indicators for assessing the accessibility of medical care is the number of physicians [Damiran, Dorjdagva, Sukhbaatar, 2022]. However, "physician accessibility" without "hospital accessibility" cannot serve as an adequate measure of the health system's efficiency. Moreover, despite the accessibility of medical care being formally high, there are factors depreciating the obtained values. Graves, Abshire and Alejandro [2022] found that, regardless of the close proximity of hospitals, residents of rural areas in the United States tend to utilize healthcare services less frequently due to low incomes and lack of the insurance coverage. Katkova [2020], presenting the results of health care coverage in Russia, links this indicator with resource metrics. It was found that the number of households, in whose budgets the share of health care costs did not exceed 10 % of their total financial resources, increased from 30 to 40 %.
The quality of medical care is also a multivariate metric and is often based on subjective assessments. However, there are studies illustrating that the key indicator of the quality is the human factor [Trakakis et al., 2022]. At the same time, it is not only the professional qualification of the physician that is of importance, but also other parameters that determine their competence. For example, an analysis of the extent to which physicians and nurses in the Russian Federation use information and communication technologies reveals that about 30 % of them lack digital competencies [Kolennikova, 2022].
Thus, when determining the social efficiency of the health care system, it is important to correlate the real needs of the population per unit time (the number of specific groups of diseases) and the availability of specialists with the required qualifications (physicians of a certain specialisation). It is this elaboration of relative indicators that can serve as the basis for an appropriate assessment.
When forming the analysis tools, it is also important to rely on the following principles:
1) to take into account the factor of "fairness" of the health care system, which implies measuring the quality and accessibility of medical care for each potential patient. That is why it is essential to assess the costs (direct and indirect) of the patients for medical care, as well as to evaluate public health financing per patient (or, in Russian practice, per 1,000 or 10,000 population);
2) to consider the demand for a particular type of medical services and their supply per unit time. In other words, it is not so much the number of physicians that is important, but the productivity of their work, which depends on the number of diseases corresponding to their professional competences.
The assessment of the ratio of medical care quality and accessibility indicators for particular specialisations was taken as the case study. The empirical evidence for testing of the proposed approach includes data from the Russian Federal State Statistics Service (Rosstat) for the period of 2012-20211. It is worth noting that it is very difficult to compare these publicly available data. For instance, the reports do not contain data in terms of most of medical specialists (cardiologists, oncologists, hematologists, endocrinologists). There is no relevance between the groups of diseases and physicians' specialisations, etc. This proves once again that health care statistics should be interpreted with great care.
The algorithm for this assessment consisted of several stages (Table 1).
Table 1. Algorithm for assessing the ratio of indicators characterising the accessibility
and quality of medical care in Russia
Stage Description
1. Prerequisites and assumptions The basic assumption is that it is impossible to integrate the medical care accessibility and quality indicators when assessing the level of efficiency of the health care system. To obtain an adequate assessment, it is necessary to correlate these indicators with each other
2. Tool selection for analysis Selecting statistical indicators that illustrate the accessibility and quality of medical care
3. Data collection Collecting data that characterise the health care system in the Russian Federation in the period of 2012-2021: • the number of physicians per 10,000 population (by specialisation); • the number of hospital beds per 10,000 population (by specialisation); • the number of operations (per 10,000 population); • the number of diseases per 10,000 population (by group)
4. Data processing 1) calculating the number of hospital beds per one physician; 2) calculating the real labour productivity of a physician
5. Interpretation of results Making conclusions regarding the medical care quality in dynamics and with individual disease groups taken into account
1 Rosstat. Health care. https://rosstat.gov.ru/folder/13721. (In Russ.)
Calculations of the expected (measured in the number of hospital beds per one physician) and real (considering the number of diseases of the corresponding group per one physician) labour productivity of medical specialists in the Russian Federation for the period of 2012-2021 are presented in Table 2.
Table 2. Calculation of the health care system indicators in the Russian Federation by various medical specialisations, 2012-2021
Indicators* 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
General practice
Number of physicians 11.7 11.7 11.1 10.9 11.1 11.5 11.8 12.0 12.4 12.6
Number of hospital beds 21.1 20.5 19.2 18.2 17.6 17.6 17.4 17.3 13.6 14.7
Number of hospital beds per one physician 1.80 1.75 1.73 1.67 1.59 1.53 1.47 1.44 1.10 1.17
Surgery
Number of physicians 5.0 4.9 4.7 4.6 4.9 5.0 5.1 5.2 5.4 5.4
Number of hospital beds 17.9 17.5 16.5 15.8 15.5 15.3 15.2 15.1 12.4 13.2
Number of operations 1,164 1,187 1,189 1,191 1,201 1,216 1,228 1,256 1,039 1,140
Number of hospital beds per one physician 3.58 3.57 3.51 3.43 3.16 3.06 2.98 2.90 2.30 2.44
Number of diseases of the corresponding group per one physician 233 242 253 259 245 243 241 241 192 211
Gynaecology**
Number of physicians 5.7 5.7 5.5 5.4 5.5 5.6 5.6 5.6 5.6 5.6
Number of hospital beds 8.4 7.9 7.3 6.8 5.4 6.2 6.1 6.0 4.6 5.0
Number of diseases*** 7.8 7.76 7.73 7.36 6.95 6.72 6.33 6.15 5.75 5.75
Number of hospital beds per one physician 1.47 1.39 1.33 1.26 0.98 1.11 1.09 1.07 0.82 0.89
Number of diseases of the corresponding group per one physician 1.37 1.36 1.41 1.36 1.26 1.20 1.13 1.10 1.03 1.03
Ophthalmology
Number of physicians 1.2 1.2 1.2 1.2 1.2 1.2 1.3 1.3 1.3 1.3
Number of hospital beds 1.7 1.6 1.5 1.4 1.4 1.4 1.4 1.4 1.1 1.2
Number of diseases 3.52 3.5 3.47 3.33 3.26 3.16 3.14 3.00 2.39 2.49
Number of hospital beds per one physician 1.42 1.33 1.25 1.17 1.17 1.17 1.08 1.08 0.85 0.92
Number of diseases of the corresponding group per one physician 2.93 2.92 2.89 2.78 2.72 2.63 2.42 2.31 1.84 1.92
Dermatovenerology
Number of physicians 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8 0.8
Number of hospital beds 1.1 1.1 1.0 0.9 0.8 0.8 0.8 0.8 0.7 0.7
Number of diseases 4.8 4.7 4.63 4.4 4.26 4.1 4.03 4.07 3.4 3.56
Number of hospital beds per one physician 1.38 1.38 1.25 1.13 1.00 1.00 1.00 1.00 0.88 0.88
Table 2 (concluded)
Number of diseases of the cor-
responding group per one phy- 6.00 5.88 5.79 5.50 5.33 5.13 5.04 5.09 4.25 4.45
sician
Otorhinolaryn gology
Number of physicians 0.9 0.9 0.9 0.9 0.9 0.9 0.9 0.9 1.0 1.0
Number of hospital beds 1.4 1.4 1.3 1.2 1.2 1.2 1.2 1.1 0.9 1.0
Number of diseases 2.82 2.8 2.77 2.66 2.63 2.59 2.55 2.5 2.05 2.13
Number of hospital beds per one physician 1.56 1.56 1.56 1.56 1.56 1.56 1.56 1.56 1.40 1.40
Number of diseases of the cor-
responding group per one phy- 3.13 3.11 3.08 2.96 2.92 2.88 2.83 2.78 2.05 2.13
sician
Notes: * All absolute figures are presented per 10,000 population. ** Per 10,000 women. *** Due to the lack of statistics, data on complications of pregnancy, childbirth and the postpartum period were taken.
Calculations of the ratio of the indicators illustrating the medical care accessibility in dynamics for certain groups of diseases allow us to draw the following conclusions.
In most cases, the growth rates of the indicators' absolute values presented in the statistical reports are improving, i.e., while the number of physicians remains constant, the number of diseases is decreasing, which also correlates with the reduction in the number of hospital beds.
However, the dynamics of this reduction proves that over the past decade the accessibility of medical care by specialisation has decreased by 30-60 %. The number of diseases during the period under consideration has also dropped. In addition, the decrease was recorded in 2020-2021 in therapy, which is directly related to the treatment of COVID-19. Such statistics are quite surprising, since theoretically indicators should be worsening due to population aging factors, man-made environmental pollution, pandemics, etc.
Along with this, formal statistics demonstrate a slow but steady increase in the number of medical workers of the specialisations reviewed, which indicates a drop in their labour productivity. A natural question that arises is why do medical personnel work less efficiently amid medical technologies being permanently improved? Does this mean that quality is rising (more time is spent for each patient), or, on the contrary, there are reasons (primarily related to business processes deterioration) that make the medical staff's work less productive?
The results of the study show that the Russian health care system is being restructured and accessibility of medical services is in decline. However, this does not imply an increase in its quality, which, to be determined, needs additional measurements.
Conclusion
The problem of the health care system efficiency can be resolved through effective allocation of resources.
"Is the high quality of medical care always justified in terms of welfare? From the ethical standpoint, the answer to this question is obvious. But from an economist's viewpoint, investments in the quality of medical care should be weighed against costs and alternative investment options for limited resources" [Sheyman, 2007, p. 41].
Finding the "right" balance between the quality and the quantity of medical services (their accessibility) is a complex task which is difficult to operationalise, since the very category of medical care quality is multivariate and needs to be elaborated. The quality of what should be monitored in health care? What are the methods for monitoring this quality supposed to be? How to build a quality control system in health care? In which way does job satisfaction affect the quality of staff work? and so on.
Thus, the problems of measuring quality and accessibility indicators are fundamental in determining the state of the health care system. The present research starts a series of publications on the topic in question. Correlating the efficiency of interaction between different stakeholder groups can underlie the formation of an integrated approach to evaluating the health care system efficiency.
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Information about the author
Mikhail A. Safarov, Chief Medical Officer. OOO "Polymedika", Chelyabinsk, Russia. Email: m_safarov@mail.ru
© Safarov M. A., 2023
