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Directions and mechanisms of forming integrated, transparent and efficient health system

Priority areas of development: state and public administration

Object of Research: health care system and health finance system.

Goal of Research – analysis of key factors of enhancing health system efficiency

 The study includes four components:

  1. The effectiveness of the system of mandatory health insurance (MHI)
  2. Experience and prospects to improve the quality of care using standards of care
  3. Mechanisms for enhancing the role of patients in the health system
  4. Mechanisms of change in the motivation of medical workers.

Empirical base of Research:

  • WHO and OECD database,
  • results of in-depth interviews with medical workers on the transition to effective contract,
  • data from a survey of 95 health insurance companies about the parameters of activity in terms of the new law on compulsory health insurance HSE conducted in July-August 2014,
  • RLMS data,
  • data of the survey of health workers conducted by HSE with the organizational support of the Ministry of Health of Russia in 12 subjects of the Russian Federation in September-October 2013. The total number of respondents was 4874 persons,
  • data of the survey of health workers conducted by HSE and Levada Center in 4 subjects of the Russian Federation in September-October 2014. The total number of respondents was 2000 persons.

Results of Research

1) The internationalcomparison of the effectiveness of budgetary and insurance models of health care financing in the post-socialist countries is conducted. The data for 28 countries for the 1991-2012 are used, and the calculations are made on the basis of multivariate regression model. The hypothesis of generating by the insurance model more sustainable health funding relative to the budgetary model is supported.  The hypothesis of its higher impact on health outcome is partly supported (most of mortality indicators are lower in the insurance model when other variables are controlled). Health insurance model does not generate a higher number of hospital admissions (relative to the budgetary model), but ensures some relative decrease in the average length of hospital stay while the efficiency of hospital beds use is the same. That is the hypothesis of the health insurance model higher impact on structural efficiency is partly supported. The general conclusion is that the insurance model in the post Soviet countries demonstrates some advantages but they are not substantial. 

2) The study of the role of health insurance companies in the reformed Russian MHI shows that citizens became themselves increasingly making use of their right to choose directly, without intermediaries, health insurance organization.

 In 2014, the level of competition for insured in the CHI services increased significantly compared to 2012. The activity of health insurance companies to conduct assessments of quality of care increased and efforts to influence on its improvement have been intensified. However, the implementing of insurance companies’ proposals to improve the quality of health care  remains low.

3)  The review of the experience of the development of Russian standards of care for diseases shows that methodology of development of evidence based guidelines has been not accepted. The control over conflict of interest of participants of the development of the guiding documents is not developed. Economic factors are not systematically addressed in decisions on provision of health care interventions. The practice of the health technology assessment is not developed. The recommendations are provided on the need for procedural requirements for the organization of the development of standards and technological requirements to develop clinical guidelines, requirements for cost-effectiveness analysis, and the integration of economic evaluations into standards.

4) The possibilities of changing the role of the patient in the Russian health care system by providing it with the right of free choice of doctors and medical organizations are examined. On the one hand, such policy can have a strong positive impact on the quality of care and efficiency of the health system. But on the other hand, there are risks and additional costs for the introduction of mechanisms that weaken these risks. Comparison of these benefits and risks suggests the feasibility of expanding the right choice, but by gradual removal of appropriate restrictions.

5) The results of a 2014 survey of medical workers on salary and transition to the effective contract and comparison them with those of a similar survey in 2013 testify the stability in the hierarchy of incentives for better performance. Fair remuneration is strongest incentive for all categories of medical workers.  All other possible incentives are significantly less important.

Approximately two-thirds of respondents reported that, in their opinion, the volume of work has increased markedly, and the salary in 2014 increased slightly. It's not yet led to positive changes in their work motivations. The majority of medical workers had the firm conviction that their work is undervalued. They saved paternalistic orientation with respect to the government and the administration of health facilities. This orientation is connected with the idea of injustice in wages, the duty of the state to the medical community, but not with the readiness to engage in reforms. The  transition to effective contract is identified in the minds of the medical workers with higher remuneration for the same work as before.

6) The possibilities of introducing the economic responsibility of physicians for the results of medical care are analyzed. The subject of the analysis is the obstacles that exist in the Russian legislation for the implementation of the possible schemes for conversion of a doctor in a subject with personal civil liability for injury to the patient due to the failure of medical intervention The introduction in the Russian Federation of such liability in relation to doctors working in medical institutions requires the abandon the model of general delict that would entail the need for a radical change of the existing civil legislation, that is unrealistic and irrational.

Level of implementation,  recommendations  on implementation or outcomes of the implementation of Results:

Research outcomes can be used for the specification of objectives and tools of state policy of health insurance, ensuring improved quality of care, and transition to effective contract with medical workers.

Field of application: health care system and health finance system


Шишкин С. В., Бурдяк А., Потапчик Е. Г. Роль выбора пациентов в российской системе здравоохранения / Высшая школа экономики. Series WP8 "Государственное и муниципальное управление". 2014. 
Шишкин С. В., Потапчик Е. Г., Селезнева Е. В. Оплата пациентами медицинской помощи в российской системе здравоохранения. / Высшая школа экономики. Series WP8 "Государственное и муниципальное управление". 2014. 
Чирикова А. Е. Готовы ли сегодня профессиональные медицинские организации обеспечить профессиональный рост врачей в России, in: Профессиональные группы: сообщества, деятельность и карьера. Москва : ИС РАН; РОС, 2014. С. 34-78. 
Тарасенко Е. А., Чирикова А. Е. Государство и профессиональные медицинские организации: кто реально способен обеспечить профессиональный рост врачей в России? // Электронный научный журнал "Социальные аспекты здоровья населения". 2014. № 4(38). 
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Sheiman I. Integrated Health Care Payment Methods: Typology, Evidence And Pre-Conditions Of Implementation / Высшая школа экономики. Series PA "Public Administration". 2014. No. WP BRP 18/PA/2014. 
Marten R., McIntyre D., Travassos C., Shishkin S., Longde W., Reddy S., Vega J. An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS) // The Lancet. 2014. Vol. 384. No. 9960. P. 2164-2173. doi
Шишкин С. В., Чирикова А. Е. Взаимодействие врачей и пациентов в современной России: векторы изменений // Мир России: Социология, этнология. 2014. № 2. C. 154-182. 
Шишкин С. В. Российская система здравоохранения: трудный путь реформ, in: Алексеев М., Вебер Ш. (ред.) Экономика России. Оксфордский сборник. – М.: Издательство Института Гайдара, 2015. Книга 2..: Издательство Института Гайдара, 2015. С. 1263-1302.