CC BY
0DOI: 10.29141/2658-5081-2024-25-2-5 EDN: QRISWP JEL classification: I15
Natalya V. Krivenko Institute of Economics (Ural branch of RAS), Ekaterinburg,
Russia
The level of medical care accessibility in Russia: Regional differentiation
Abstract. The need to consider economic risks and respond to demographic challenges pushes the issues of creating and maintaining the quality of regions' human potential, as well as saving population health to the research agenda. The aim of the study is to investigate the resourcing of regional health care systems in Russia in order to determine the level of medical care accessibility. Methodologically, the paper relies on the concepts of systems and regional economics, labour economics. The study applies time series and comparative analyses, as well as index, score-rating methods, composite coefficients calculation. The data is the socioeconomic and health care statistics by federal districts for 2005-2022 taken from the Federal State Statistics Service of the Russian Federation. The paper finds that regions differ in terms of the level of the medical care accessibility. Reportedly, the Ural Federal District ranked high for the efficiency of regional health care systems in 2021, which, according to the analysis, is due to the developed systems of preventive and emergency care. Conversely, the Siberian and Far Eastern Federal Districts were at the bottom of the ranking because of the deficit of physicians in emergency departments and scarce health care financing. The findings may underlie the development of measures on the improvement of health care resourcing, management, and efficiency both at national and regional levels.
Keywords: Russia's regions; regional health care; accessibility of medical care; resourcing; health care efficiency.
Funding: The research was prepared in accordance with the R&D Plan for the Institute of Economics (Ural Branch of RAS).
For citation: Krivenko N. V. (2024). The level of medical care accessibility in Russia: Regional differentiation. Journal of New Economy, vol. 25, no. 2, pp. 89-107. DOI: 10.29141/2658-5081-2024-25-2-5. EDN: QRISWP.
Article info: received February 18, 2024; received in revised form March 20, 2024; accepted March 26, 2024
Introduction
The second wave of sanctions has become another challenge for the Russian economy. The impact of sanctions on Russian companies can be viewed both from the theoretical standpoint (institutional, resource, behavioural theories) and from the empirical standpoint [Simachev et al., 2023, p. 5]. By the end of spring 2022, about 60 % of companies suffered from sanctions, and the main problems and risks were related to difficulties in accessing imported raw materials and components, rising domestic and import prices, falling effective demand and increasing general uncertainty in the economy [Kuvalin et al., 2022, p. 171]. The main consequences of the sanctions restrictions for the Russian business are the disruption of logistics chains, the reduction of the customer base, payment difficulties and a lack of highly qualified personnel [Koroleva, 2023, p. 516].
For the successful socioeconomic development of Russia it is of particular importance to preserve the human potential of the population, including labour potential, the quality of which is determined by the level of education, professional skills and health state. In the current geopolitical situation, Russia's need for the formation and preservation of the human capital is increasing [Neshataev, 2023, p. 123].
Many scientists, when assessing human capital consider both education and health protection [Mincer, 1958, p. 290; Schultz, 1961, p. 10; Becker, 1962, p. 15; Hall, Jones, 1999, p. 93; Badinger, Tondl, 2003, p. 220; Dhal, 2019; Bosi, Lloyd-Braga, Nishimura, 2021], and the main result of the human capital, that is, the productivity of the country's economy as well as the impact of health on the economic growth of countries and regions [Grossman, 1972, p. 230; Barro, 2013, p. 332; Rodríguez-Pose, Villarreal Peralta, 2015, p. 180; Chetty et al., 2016, p. 1760; Yang, 2020, p. 170]. The consideration includes the activities of government bodies and the level of public health and education expenditure, which affect the formation and use of human capital.
The Institute of Socioeconomic Problems of Population of the Russian Academy of Sciences offers the following approach to the structure of human potential, consisting of three basic subsystems: demographic (biosocial), socioeconomic (labour) and socio-cultural (moral).
The weakest link in the human potential of modern Russia is its demographic component [Lokosov, 2023, p. 5]. Among the current challenges and threats, including the war of sanctions declared against Russia, attention should be paid to demographic threats that affect the preservation of the human potential of the population, including labour potential. The difficult demographic situation in Russia requires urgent government solutions. The country's ability to cope with the growing tension of international economic, political and military conflicts, as
well as external and internal risks and threats, depends on its population preservation [Ageev et al., 2023, p. 39].
Traditionally, health care has been classified as a non-productive sector, with the end result viewed as non-productive services. Human health should be considered as a special socioeconomic product that significantly affects the economic development of the territory and the well-being of the population living there [Bochko, Bukin, 2012, p. 128]. Studies on the impact of employees' health on wages show that good health contributes 3-4 % to wages, while poor health reduces wages by 9 %. [Kaneva, Zabolotskiy, Moroshkina, 2023, p. 76].
The state of the population's health, in turn, largely depends on the resourcing and efficiency of health care systems in the regions of Russia. The preservation and accumulation of health capital in the current economic situation in the context of increased sanctions is intended to contribute to boosting labour productivity and become a source of economic growth at the level of the country and its regions.
The period of 2007-2008 saw a positive dynamics of birth rates in Russia resulting from the intensification of family demographic policy with the best indicators achieved in 2012-2016. The natural growth in 2013-2016 did not last long and was replaced by depopulation since 2017, although the state took new measures to improve the demographic situation. Under the COVID-19 pandemic the negative dynamics of Russia's demographic development indicators continued: an increase in population mortality and a decrease in the birth rate [Zyryanova, 2022, p. 906].
The decline in the country's population is accompanied by a decline in resources in the Russian health care system. In 1990-2021, the number of hospital beds per 10,000 persons decreased 1.75 times - from 138 to 79.1 thousand, and the number of health facilities in the same period decreased 2.5 times - from 12.8 to 5.1 thousand [Ageev et al., 2023, p. 43]. Various studies have used population surveys to show inhibiting and encouraging factors for the birth rate. The negative reasons include the lack of high-quality and affordable medicine, the deterioration of medical care, and an inadequately developed health care infrastructure in rural areas, which is also a consequence of "optimisation" in the industry [Zyryanova, 2022, p. 906].
The purpose of the paper is to investigate the resourcing of regional health care systems in order to determine the level of medical care accessibility for the population of Russia.
The objectives can be stated as follows:
- to identify trends in the resourcing of regional health care systems through the analysis of socioeconomic and health statistics by federal districts of the Russian Federation;
- to calculate the composite coefficients of resourcing and compare them with the efficiency ranking of regional health care systems;
- to determine the level of medical care accessibility to the population.
Analysis of resourcing indicators of regional health care systems
The study of regional differentiation of the medical care accessibility in Russia relies on the systems, multilevel and comprehensive approaches.
Table 1 shows an analysis of the hospital beds provision by federal districts of the Russian Federation for the period 2005-2022.
Table 1. Analysis of the hospital beds provision by federal districts of the Russian Federation, 2005-2022
Federal district 2005 2010 2015 2020 2021 2022 2022 to 2005, % Rank in the RF, 2021
Russian Federation
Number of hospital beds per 10,000 population 110.9 93.8 83 80.6 79.1 78 70.3 -
Population per 1 hospital bed, persons 90.2 106.7 120.4 124 126.5 128.3 142.2 -
Central Federal District
Number of hospital beds per 10,000 population 112.4 92.3 77.4 77.2 72.3 70.5 62.7 7
Population per 1 hospital bed, persons 89.0 108.4 129.2 129.5 138.2 141.8 159.3 -
Northwestern Federal District
Number of hospital beds per 10,000 population 108.0 93.2 85.9 80.8 80.9 81.6 75.6 4
Population per 1 hospital bed, persons 92.6 107.2 116.5 123.8 123.6 122.5 132.3 -
Southern Federal District
Number of hospital beds per 10,000 population 104.8 90.7 68.7 77.4 77.6 77.7 74.1 6
Population per 1 hospital bed, persons 95.5 110.2 145.5 129.1 128.8 128.7 134.8 -
North Caucasian Federal District
Number of hospital beds per 10,000 population 82.3 78.0 72.3 75.2 69.1 67.4 81.9 8
Population per 1 hospital bed, persons 121.5 128.2 138.3 133.0 144.8 148.4 122.1 -
Table 1 (concluded)
Federal district 2005 2010 2015 2020 2021 2022 2022 to 2005, % Rank in the RF, 2021
Volga Federal District
Number of hospital beds per 10,000 population 111.7 91.9 83.3 79.5 79.4 79.3 71.0 5
Population per 1 hospital bed, persons 89.5 108.9 120.1 125.8 12.0 126.1 140.9 -
Ural Federal District
Number of hospital beds per 10,000 population 110.1 94.0 82.6 80.7 82.9 79.7 72.4 3
Population per 1 hospital bed, persons 90.8 106.4 121.1 123.9 120.6 125.4 138,1 -
Siberian Federal District
Number of hospital beds per 10,000 population 119.5 104.6 105.7 89.7 89.6 88.7 74.2 2
Population per 1 hospital bed, persons 83.7 95.6 94.6 111.5 111.6 112.7 134.6 -
Far Eastern Federal District
Number of hospital beds per 10,000 population 126.0 108.4 77.8 95.7 96.5 93.7 74.4 1
Population per 1 hospital bed, persons 79.4 92.2 128.5 104.4 103.7 106.7 134.4 -
Source: Regions of Russia. Socioeconomic Indicators 2023: Statistical Yearbook (pp. 366-413). Moscow: Rosstat. https://rosstat.gov.ru/folder/210/document/13204. (In Russ.)
The number of hospital beds per 10,000 persons decreased by an average of 30 % in Russia as a whole and separately in the regions. Accordingly, the load on the bed grew up - the number of persons per bed increased by 42.2 %. Taking into account the fact that the assessment of regional health care systems is carried out on the basis of statistics for 2021, the study uses some indicators for 2021 to evaluate hospital beds in the subjects of the Russian Federation.
The Far Eastern, Siberian and Ural Federal Districts were among the three regions best equipped with hospital beds in 2021.
The decline in inpatient care in the country's health care system was accompanied by an increase in the burden on the outpatient medical care for the whole of Russia by 16.8 % during 2005-2022. Table 2 shows the capacity indicators of outpatient care services in federal districts of the Russian Federation for the period.
Table 2. Outpatient care services capacity per 10,000 population in federal districts of the Russian Federation, visits per shift
Federal district 2005 2010 2015 2020 2021 2022 2022 to 2005, % Rank in the RF, 2021
Russian Federation 256.0 257.9 262.3 281.3 289.4 299.1 116.8 -
Central Federal District 268.9 268.8 267.5 283.2 305.6 325.4 121.0 4
Northwestern Federal District 293.6 297.0 304.7 333.3 344.3 350.3 119.3 1
Southern Federal District 227.4 235.6 229.9 235.8 242.1 245.7 108.0 7
North Caucasian Federal District 161.9 168.8 175.2 225.1 185.9 181.8 112.3 8
Volga Federal District 236.2 245.0 261.3 278.5 279.5 284.8 120.6 6
Ural Federal District 268.4 275.3 279.5 303.6 313.5 318.8 118.8 2
Siberian Federal District 291.5 281.1 280.1 296.1 304.9 313.9 107.7 5
Far Eastern Federal District 252.4 255.6 275.6 291.6 309.3 328.6 130.2 3
Source: Regions of Russia. Socioeconomic Indicators 2023: Statistical Yearbook (pp. 366-413). Moscow: Rosstat. https://rosstat.gov.ru/folder/210/document/13204. (In Russ.)
The capacity of outpatient care increased by 116.8 % over the period under review. The top three in terms of outpatient care capacity in 2021 included the Northwestern, Ural, and Far Eastern Federal Districts. In Table 3 we analysed the change in the sufficiency with physicians and nurses and the change in the workload of medical staff over the same period.
In 2005-2022, throughout the Russian Federation and separately by regions, with the exception of the Siberian Federal District, there was an upward trend in the number of physicians per 10,000 population and a downward trend in the physicians' workload - population per one physician.
In the Siberian Federal District, with a decrease in the number of physicians, their workload has increased.
The three leaders in terms of the physicians' number are Northwestern, Far Eastern and Central Federal Districts.
In 2005-2022, throughout the Russian Federation and separately by regions, with the exception of the North Caucasian Federal District, the number of nurses per 10,000 population was declining while the population per one nurse going up.
In the North Caucasian Federal District, with an increase in the number of nurses, their workload has decreased.
The top three in terms of the nurses' number include Ural, Far Eastern and Siberian Federal Districts (see Table 3).
Table 3. Analysis of the sufficiency with physicians and nurses and the workload of medical staff in federal districts of the Russian Federation, 2005-2022
Federal district 2005 2010 2015 2020 2021 2022 2022 to 2005, % Rank in the RF, 2021
Russian Federation
Number of physicians per 10,000 population, persons 48.6 50.1 45.7 50.0 50.5 50.8 104.5 -
Population per one physician, persons 205.8 199.6 218.7 200.0 198.1 196.8 95.6 -
Number of nurses per 10,000 population, persons 107.7 105.6 105.3 101.1 99.9 98.3 91.3 -
Population per one nurse, persons 92.9 94.7 95.0 98.9 100.1 101.7 109.5 -
Central Federal District
Number of physicians per 10,000 population, persons 50.9 53.5 45.5 52.1 53.2 54.0 106.1 3
Population per one physician, persons 196.6 187.0 219.8 191.8 188.0 185.1 94.2 -
Number of nurses per 10,000 population, persons 102.2 99.8 96.6 92.7 91.6 90.7 88.7 7
Population per one nurse, persons 97.9 100.2 103.6 107.8 109.2 110.2 112.6 -
Northwestern Federal District
Number of physicians per 10,000 population, persons 54.3 57.8 54.5 61.6 62.8 63.2 116.4 1
Population per one physician, persons 184.2 173.0 183.6 162.4 159.3 158.2 85.9 -
Number of nurses per 10,000 population, persons 110.5 108.5 111.7 106.3 105,0 104.6 94.7 4
Population per one nurse, persons 90.5 92.1 89.6 94.1 95.3 95.6 105.6 -
Southern Federal District
Number of physicians per 10,000 population, persons 43.6 44.4 41.5 43.9 44.0 44.3 101.6 7
Population per one physician, persons 229.4 225.3 240.9 227.7 227.1 225.6 98.3 -
Number of nurses per 10,000 population, persons 95.9 95.7 96.2 92.3 90.4 88.1 91.9 8
Population per one nurse, persons 104.3 104.5 104.0 108.4 110.6 113.5 108.8 -
North Caucasian Federal District
Number of physicians per 10,000 population, persons 42.5 40.1 39.2 43.4 43.3 43.7 102.8 8
Table 3 (concluded)
Federal district 2005 2010 2015 2020 2021 2022 2022 to 2005, % Rank in the RF, 2021
Population per one physician, persons 235.3 249.5 255.4 230.5 231.0 228.7 97.2 -
Number of nurses per 10,000 population, persons 89.4 88.5 90.5 94.1 94.4 93.8 104.9 6
Population per one nurse, persons 111.9 113.0 110.5 106.2 105.9 106.6 95.3 -
Volga Federal District
Number of physicians per 10,000 population, persons 46.7 47.2 45.0 47.5 47.6 47.5 101.7 5
Population per one physician, persons 214.3 211.7 222.1 210.4 210.0 210.6 98.3 -
Number of nurses per 10,000 population, persons 115.5 112.3 112.0 105.9 104.6 102.2 88.5 5
Population per one nurse, persons 86.8 89.0 89.3 94.4 95.6 97.8 112.7 -
Ural Federal District
Number of physicians per 10,000 population, persons 42.5 46.0 43.1 47.1 47.4 48.2 113.4 6
Population per one physician, persons 235.5 217.2 231.9 212.3 210.9 207.4 88.1 -
Number of nurses per 10,000 population, persons 115.3 116.3 116.3 113.3 111.6 110.6 95.9 1
Population per one nurse, persons 87.6 86.0 86.0 88.2 89.6 90.4 103.2 -
Siberian Federal District
Number of physicians per 10,000 population, persons 51.6 52.4 47.2 49.5 49.8 49.5 95.9 4
Population per one physician, persons 193.8 190.8 212.1 202.0 200.9 202.2 104.3 -
Number of nurses per 10,000 population, persons 114.1 111.8 114.1 108.0 107.0 104.8 91.8 3
Population per one nurse, persons 87.6 89.5 87.7 92.6 93.9 95.5 109.0 -
Far Eastern Federal District
Number of physicians per 10,000 population, persons 52.3 54.2 51.8 54.7 54.5 54.4 104.0 2
Population per one physician, persons 191.2 184.6 193.0 182.7 183.6 184.0 96.2 -
Number of nurses per 10,000 population, persons 111.8 111.0 113.7 110.3 109.1 106.5 95.3 2
Population per one nurse, persons 89.5 90.1 87.9 90.7 89.6 93.9 104.9 -
Source: Regions of Russia. Socioeconomic Indicators 2023: Statistical Yearbook (pp. 366-413). Moscow: Rosstat. https://rosstat.gov.ru/folder/210/document/13204 . (In Russ.)
We note a rising demand for medical services, including high-tech services, in Russia, which is associated with an aging population and high morbidity. This leads to a need to increase health care costs. The problems of population aging in developed countries led to the growth of health care in government expenditure by 10-15 % [Chubarova, 2023, p. 6].
The so-called "optimisation", the COVID-19 pandemic, the energy crisis and increased inflationary pressure made their negative contribution to the resourcing of the Russian health care system in the reporting period. The pandemic has been replaced by a new challenge - logistical difficulties in the supply of medicines and medical devices within the constraints of the sanctions.
Health care expenditures of the consolidated budget of the Russian Federation and the budgets of state extra-budgetary funds expressed as a percentage of GDP for 2015-2021 amounted to 3.4 % in 2015, 3.5 % in 2019, 4.6 % in 2020, 3.8 % in 20211. At the level of the Russian Federation subjects, the expenditure of consolidated budgets on health care increased in the period 2015-2022, with the exception of the North Caucasian Federal District. However, consolidated budget expenditures in 2022 compared to 2021 increased only in the Ural and Northwestern Federal Districts. In the remaining districts we see a decline in health spending2.
The investments in fixed assets for Russia's health care stagnated, expressed as a percentage of total investments in fixed assets they amounted to 1.7 % in 2019, 2.8 % in 2020, 2.5 % in 2021, 2.5 % in 20223. The first three in terms of investments in fixed assets in the field of health care and social services were the Central, Volga and Northwestern Federal Districts4.
At the same time, the degree of depreciation of fixed assets in the Russian health care system remained significant: 52.9 % in 2019, 52.2 % in 2020, 52.7 % in 2021, 54.2 % in 20225.
Given the increasing depreciation of fixed assets and insufficient investments, Russia continues to lag behind in financing health care compared to developed countries, which affects the country's ratings in international comparisons of medical and demographic indicators.
In terms of life expectancy (considered a basic indicator of the socio-demographic area), Russia ranked 134th in the world in 2021. One of the reasons for the deterioration in public health is the increase in the share of the population's own resources in health financing in the Russian Federation. This share has grown from 17 to 48 % over
1 Health Care in Russia. 2023: Statistical Yearbook. Moscow: Rosstat, 2023. (In Russ.)
2 Health care in Russia. 2023: Statistical Yearbook. Appendix to the Yearbook. Moscow: Rosstat, 2023. (In Russ.)
3 Health Care in Russia. 2023: Statistical Yearbook. Moscow: Rosstat, 2023. (In Russ.)
4 Regions of Russia. Socioeconomic Indicators 2022: Statistical Yearbook. Moscow: Rosstat, 2022. (In Russ.)
5 Health Care in Russia. 2023: Statistical Yearbook. Moscow: Rosstat, 2023. (In Russ.)
the last 30 years, although the World Health Organisation considers 20 % to be the maximum critical value of this indicator [Lokosov, 2023, p. 6].
The presented analysis shows that the parameters of state financing of health care in the Russian Federation for 2020-2024 remain low, which will lead to a decrease in their volumes at constant prices by 4 % and will not solve important problems of the sphere under consideration: shortage of medical staff; insufficient expenditures for free outpatient drug coverage; lack of free medical care and financial resources for its provision. The problems of ensuring available free medical care to the population of the Russian Federation are exacerbated by the growing influx of patients requiring treatment for complications following COVID-19 infection, as well as patients whose medical care was postponed during the pandemic [Ulumbekova, Alvianskaya, 2021, p. 40].
The trends revealed indicate the existing problems in ensuring the population's access to free medical services during the period under consideration.
Resourcing and efficiency of regional health care systems
We use an index method to assess the resourcing of regional health care systems. The composite resourcing coefficient was determined for each federal district as the product of the coefficients of the ratio of actual indicators to the national average, which was taken as a standard value equal to one. The ratio of actual indicators to the national average was calculated by region (Table 4).
Table 4. Assessment of resourcing and efficiency of regional health care systems by federal districts of the Russian Federation as of 2021
Federal district <4_, OS O "O SP tu .5 tí tu — •s i i . SH tu n ^ 3 <3 tí ÖJD t 5 i x tu tí tí <-i-i . S * ÖP -H •s .5 g ink by resourcing, >21
o bE ^ a CÄ QJ & C b u .-tí 3 ^ ° O tí & ^ & 0J r\ O E £ O € £ CÄ QJ C o =« O
p¿ <J -tí tí PS o O o P¿ O O, á 3 c u a 8 & <3
Russian Federation 79.1 (C=1.00) 289.4 (C=1.00) 50.5 (C=1.00) 99.9 (C=1.00) C=1.00 -
Central Federal District 0.914 1.056 1.053 0.917 0.932 6
Northwestern Federal District 1.023 1.190 1.244 1.051 1.592 1
Southern Federal District 0.981 0.837 0.871 0.905 0.722 7
North Caucasian Federal District 0.874 0.642 0.857 0.945 0.454 8
Volga Federal District 1.004 0.966 0.943 1.047 0.958 5
Ural Federal District 1.048 1.083 0.939 1.117 1.190 4
Siberian Federal District 1.130 1.054 0.986 1.071 1.258 3
Far Eastern Federal District 1.220 1.069 1.079 1.092 1.537 2
The composite resourcing coefficient for each federal district is calculated as a product of coefficients, the standardised value is equal to one. We determined the ranks of federal districts in terms of resourcing in 2021. As can be seen from Table 4, the Northwestern, Far Eastern, and Siberian Federal Districts were among the top three in terms of resourcing of the health care systems in 2021. The last place was taken by the North Caucasian Federal District.
The performance of regional health systems is assessed using efficiency indicators. When assessing the efficiency of health care systems in Russian regions, we took into account various indicators that reflect the level of development of the medical sector and the quality of the services provided. On this basis, we ranked leaders and outsiders.
We should pay attention to such an important problem when compiling the ranking as the unavailability of some necessary information [Zolotareva, 2023, p. 126].
The efficiency ranking of regional health care systems in Russia is presented for 20211. One of the main indicators is the medical care accessibility, which is determined by the number of beds and health facilities per thousand people, as well as the availability of specialised centers ensuring high-tech medical care. Other important indicators include: the qualifications of medical personnel, their level of education and professional experience; the availability of modern equipment and materials necessary for high-quality and high-tech medical care; financial indicators; an indicator of the population's satisfaction with the medical services provided2.
Each of these criteria is evaluated taking into account its importance and contribution to the overall efficiency of the region's health care system using statistical analysis methods, expert assessments, etc. Based on the results obtained, regions are ranked according to their efficiency in Russia's health care system.
In 2021, the efficiency ranking of the Russia's regional health care systems was as follows3.
1. Central Federal District.
2. Northwestern Federal District.
3. Ural Federal District.
4. Volga Federal District.
5. Southern Federal District.
6. Siberian Federal District.
7. Far Eastern Federal District.
8. North Caucasian Federal District.
1 Ranking of Health Care Systems Efficiency by Russian Regions: Top-10 Leaders and Outsiders. https://sxemy.ru/ reiting-regionov-rassii-po-effektivnosti-sistem-zdravooxraneniya/ (In Russ.)
2 Ibid.
3 Ibid.
It is advisable to compare this ranking with the indicators determined for the resourcing of regional health care systems. Table 5 shows a comparison of the efficiency ranking of regional health care systems and composite coefficients for health care resourcing in federal districts of the Russian Federation in 2021.
The average composite resourcing coefficient is 1.0804, which is close to the data of the Volga Federal District. Depending on the rank for the efficiency of regional health care systems in Russia in 2021, the score is distributed (using the score-rating method) from 1 (North Caucasian Federal District - last 8th place) to 10 (Central Federal District - 1st place). The value of the average score (0.180) was determined by dividing the average composite coefficient for resourcing (1.0804) by the number of points (6) corresponding to the 4th place of the Volga Federal District.
Next, we calculated the efficiency ranking composite coefficients as the product of the average score and the number of points.
We used the "Golden Ratio" formula to determine the standardised ratio of the composite resourcing coefficient to the composite efficiency ranking coefficient (0.62). The ratios for federal districts were calculated. The obtained values suggest that good efficiency results were achieved with resourcing indicators close to the standard value, and not above one. With significant excesses of resourcing values, federal districts have low efficiency indicators (see Table 5).
The Central Federal District took the 6th place in terms of resourcing. An insufficient number of hospital beds and a shortage of nursing staff were identified. At the same time, the region is a leader in health care investments. The Central Federal District took 1st place in the efficiency ranking, which is explained by the influence of other factors that contribute to achieving high efficiency, including the presence of the capital region with the most developed network of well-equipped medical institutions and highly qualified medical personnel providing significant amounts of high-tech medical care.
The Northwestern Federal District is the leader in terms of resourcing among the subjects of the Russian Federation and the 2nd in the efficiency ranking in 2021. In the health care system of the Northwestern Federal District, new technologies are being actively introduced and large-scale medical reforms are being carried out. With good resourcing, high performance indicators for regional health care have been achieved.
The Ural Federal District ranked 4th in terms of resourcing among the subjects of the Russian Federation in 2021 but there is a shortage of physicians. In the 2021 efficiency ranking the Ural Federal District took 3rd place, which indicates the positive effect of other factors that contribute to a higher efficiency position. In the Ural
Table 5. Comparison of the efficiency ranking of regional health care systems and composite coefficients for resourcing in federal districts
of the Russian Federation for 2021
Federal district Composite resourcing coefficient / Rank in the RF Average composite resourcing coefficient Efficiency ranking of health care systems Score for efficiency ranking of health care systems Average score
Russian Federation (average indicators) - 1.0804 - - 0.180
Central Federal District 0.932 / 6 - 1 10 -
Northwestern Federal District 1.592/1 - 2 9 -
Southern Federal District 0.722 / 7 - 5 5 -
North Caucasian Federal District 0.454 / 8 - 8 1 -
Volga Federal District 0.958 / 5 1.0804 4 6 -
Ural Federal District 1.190/4 - 3 7 -
Siberian Federal District 1.258/3 - 6 3 -
Far Eastern Federal District 1.537/2 - 7 2 -
Federal district Composite coefficient based on the ranking of health care systems Standardised ratio of the composite coefficient for resourcing to the composite coefficient for efficiency ranking Ratio of the composite coefficient of resourcing to the composite coefficient of efficiency ranking
Russian Federation (average indicators) - 0.62 -
Central Federal District 1.801 - 0.52
Northwestern Federal District 1.621 - 0.98
Southern Federal District 0.900 - 0.80
North Caucasian Federal District 0.180 - 2.52
Volga Federal District 1.0804 - 0.89
Ural Federal District 1.260 - 0.94
Siberian Federal District 0.540 - 2.33
Far Eastern Federal District 0.360 - 4.27
Federal District, modern clinics and hospitals with the most modern equipment operate and provide medical care at a high level.
All leading regions in the ranking experience some common trends in the functioning of regional health care systems:
- the systems for disease prevention and early detection of diseases are the most developed;
- a large number of medical facilities and their accessibility allow regions to respond quickly to threats and epidemics;
- the medical staff is highly qualified and provide patients with high quality care. Innovative diagnostic and treatment methods are often used, including the use of the most modern medical equipment1.
The Volga Federal District ranked 5th in terms of resourcing among the subjects of the Russian Federation in 2021 and 4th in the efficiency ranking. It is close to the average composite coefficient for resourcing and is higher in efficiency. Modern medical centers and clinics providing high quality medical care operate in the Volga Federal District.
The Southern Federal District ranked 7th in terms of resourcing, which is due to the fact that the average Russian indicators were not achieved in all areas. However, in the 2021 efficiency ranking, the Southern Federal District took 5th place. The composite coefficient in the ranking is close to one, which indicates the use of additional factors to achieve efficiency, with the exception of resourcing. In the Southern Federal District, innovative technologies are being actively introduced and large-scale projects in the field of medicine are being developed.
The Siberian Federal District ranked 3rd in terms of resourcing among the subjects of the Russian Federation in 2021, due to a shortage of physicians. In the 2021 efficiency ranking, the Siberian Federal District took 6th place.
The Far Eastern Federal District is on the 2nd place in terms of resourcing among the subjects of the Russian Federation in 2021. In the 2021 efficiency ranking the district took 7th place.
It should be noted that the financing of health care in the Far Eastern and Siberian Federal Districts is insufficient.
The greatest contradictions were found in the Siberian and Far Eastern Federal Districts, which were in the top three in terms of resourcing of the subjects of the Russian Federation in 2021, but were at the bottom of the ranking in terms of the health care systems efficiency in 2021, which could indicate an insufficiently
1 Ranking of Health Care Systems Efficiency by Russian Regions: Top-10 Leaders and Outsiders. https://sxemy.ru/ reiting-regionov-rossii-po-effektivnosti-sistem-zdravooxraneniya/. (In Russ.)
efficient use of resources. This conclusion is confirmed by the Monitoring of indicator performance of the National Health Project in 2021\ according to which the Far Eastern and Siberian Federal Districts have the following worst indicators compared to Russian average:
- in the Far Eastern Federal District, the mortality rates of the working-age population and infant mortality have been exceeded;
- in the Siberian Federal District, the mortality rates of the working-age population, mortality from diseases of the circulatory system, mortality from neoplasms, and infant mortality have been exceeded.
A significant gap between the composite resourcing coefficients and the efficiency of health care systems in the Far Eastern and Siberian Federal Districts indicates a lack of resourcing, the need to use other factors: efficient management of medical facilities, the introduction of innovative treatment methods, etc.
Foreign experiences should be taken into account that show the advantages of digitalisation in health care from the perspective of rational resources consumption [Ellingsen, Monteiro, 2003, p. 130].
The North Caucasian Federal District received the same result - the final 8th place due to the low resourcing and the efficiency of the regional health care system. Compared to other regions, the region ranks last in terms of financing. In the North Caucasian Federal District there is a shortage of hospital beds, outpatient facilities and physicians and nursing staff, which primarily affects the accessibility of medical care and the performance of the regional health system.
We have highlighted the general trends in the functioning of regional health care systems that are beyond the scope of the assessment. The lack of medical facilities, especially in rural areas, reduces the accessibility of medical services. The quality of medical care is lower in these regions because modern diagnostic and treatment methods are not always available. There are problems in organising emergency care: the ambulance often arrives late or is missing in some areas, which leads to a delay in medical care and a worsening of the prognosis of the disease2.
A comparative analysis of the efficiency ranking of regional health care systems and composite resourcing coefficients in federal districts of the Russian Federation allows identifying gaps and reserves for improving management, enhancing the efficiency of regional health care, and increasing accessibility of medical care.
1 Regions of Russia. Socioeconomic Indicators 2022: Statistical Yearbook. Moscow: Rosstat, 2022. https://rosstat. gov.ru/storage/mediabank/Region_Pokaz_2022.pdf . (In Russ.)
2 Ranking of Health Care Systems Efficiency by Russian Regions: Top-10 Leaders and Outsiders. https://sxemy.ru/ reiting-regionov-rossii-po-effektivnosti-sistem-zdravooxraneniya/. (In Russ.)
Conclusion
The study showed the importance of resourcing for regional health systems, given, on the one hand, the pressure of sanctions, on the other hand, the chronic under-funding of the sector, the increasing depreciation of fixed assets, and the need to enhance investment in health care, which ultimately will contribute to improving the accessibility of medical care for the population of Russian regions.
There is a good reason to solve the problems of infrastructural provision of Russian health care in the face of constantly increasing costs of medical care and limited opportunities for public financing by involving public-private partnership. Foreign experience, comprehensively presented in the works of various scientists, testifies to the possibilities of public-private partnerships in health care: construction of buildings, supplying hospitals with modern medical equipment, introducing high-tech treating methods, etc. [Buso, Marty, Tran, 2017, p. 62; Kostyak et al., 2017, p. 123; Kretser, Murphy, Starke-Reed, 2017, p. 11; Bonfim, Segatto, Gon-^alves, 2018, p. 115; Comendeiro-Maal0eM et al., 2018; Chauhan, Marisetty, 2019, p. 570].
The study also revealed contradictions: achieving high efficiency of the health care system of the Central Federal District with insufficient resourcing; low efficiency indicators of health care systems in the Siberian and Far Eastern Federal Districts with a high level of resourcing.
Thus, we determined the multifaceted nature of the concept "medical care accessibility", which, in addition to resourcing, also depends on the management of regional health systems, the implementation of innovations in diagnosis and treatment, etc. The level of medical care accessibility requires further research, to identify bottlenecks and gaps in the development of regional health systems and ways to improve their efficiency.
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Information about the author
Natalya V. Krivenko, Dr. Sc. (Econ.), Lead Researcher. Institute of Economics (Ural branch of RAS), Ekaterinburg, Russia. E-mail: nvkrivenko@yandex.ru
© Krivenko N. V., 2024
