The coronavirus case count in Russia has finally stabilized due to the lockdown limiting the public’smovement and interaction, as well as the accelerated transition of the entire healthcare system to operating in a new format. The whole country has been waiting for this positive trend in the reduction of the number of infection cases for more than two months.
During this period when Russia was combating Covid-19, enormous changes occurred in absolutely all areas; from the retraining of medical personnel to rapid decision-making and legal changes. The portal "The Future of Russia. National Projects", operated by TASS, learns what lessons the novel coronavirus has taughtRussia’s healthcare system.
Semashko’s principles and how the system got tested
The mobilization to battle the coronavirus infection revealed something crucial. Russia’s healthcare system has the resources and mechanisms to quickly switch into operating in ‘combat’ conditions. Experts are convinced that the new hospitals and beds, the additional diagnostic and resuscitation equipment, and fast-track retraining of doctors - all of this should be used as a potential reserve of resources, which will not only reduce the consequences of possible epidemics in the future, but also will help to facilitate decision making and improve the quality of medical aid during times of tranquility.
They also note that our country’s success in the fight against coronavirus, namely curbing the count of the infection cases along with the low mortality rates, is in no small way attributed to the historical features of the organization of the country’s healthcare services. The principles which have been preserved since the Soviet era, were formulated by the outstanding physician and healthcare reformer Nikolai Semashko, eponymously called the Semashko system.
“Thank God we preserved it [the system — TASS] at least in the state in which it exists, and now we have every reason to believe that we will take further steps to enhance it. Actually, this is what’s happening,” noted the Russian President Vladimir Putin at an epidemiological meeting on May 22.
The Semashko system is based on the unified principles of the organization and centralization of healthcare, which helped to quickly mobilize various services for new tasks in an emergency situation.“There are more than 160,000 beds in the country, resuscitation beds allow us to feel more confident, and there is no overload,” said Russian Health Minister Mikhail Murashko at that same meeting with the president.
One can see that the effectiveness of Semashko’s principles of organization, cooperation and centralization is even more evident in the work of the medical service of the Russian Defense Ministry. In just two months, the ministry built 16 hospitals nationwide to tackle priority needs. During one of the epidemiological meetings, Putin admitted that at first, he had doubted that it would be possible to do this on such short notice.
Centralization and crisis management
As Larisa Popovich, director of the Institute for Health Economics of the Higher School of Economics (HSE), notes, during peacetime, the efficiency of decision-making suffers from overregulation. Yet, in the fight against the epidemic, it was discipline, control and empathy that turned out to be crucial.
"The government immediately brought the situation under control, and set out to coordinate cooperationamong various services, including the military, and the Ministry of Emergencies. This is very good, and this is a very serious lesson for any future actions, especially inthe healthcare system. Because health is an integrating global factor of the country’s economic development, and it is clear that the coordination of all structures - the Ministry of Agriculture, the Trade Ministry, the military, the Ministry of Transport and so on - forms a normal picture of healthcare system,” the expert explained.
If the system enables orders to be given directly from the top down, and make decisions swiftly, then it works quickly, added Popovich. Another example of strict discipline is the work of the main disease prevention service in the country, namely Russia’s sanitary watchdog.
Heads of institutions and regional officials also point to effective cooperation with Moscow. Amid the lack of information about the disease caused by the novel coronavirus, it was the nation’s capital that had tackled the largest number of cases, which meant that the experience in their treatment was accumulated there.
“We probably even somewhat longed for suchcommunication and solving a lot of joint matters on the principles of mutual respect and understanding. This is very important for us, and we would like to preserve it in the future,” Oleg Karpov, who heads the Pirogov center, said at a meeting with the president.
According to the General Director the Center for Healthcare Quality Assessment and Control of the Russian Ministry of Health Vitaly Omelyanovsky, the heads of local health authorities actually became crisis managers who had to deal primarily with tactical objectives. And often, these decisions conflicted withexisting regulatory documents that function in normal times.
“We presume that there will be few emergencies like this, but some flexibility to the healthcare system must be fashioned in order to be able to make precisely the decisions necessary at a given moment,” he said. And the Russian Ministry of Health notes that it took three-four days to adopt certain types of documents amid the epidemic, including the coordination with the Ministry of Justice.
This experience can change the role of healthcare and will make it possible to use proven means to facilitateproviding medication and bolster the availability and quality of medical care beyond the tactical objectives of battling the novel coronavirus.
Doctors now experts of sorts in communicable diseases
When the epidemic broke out, medical personnel, especially healthcare specialists focusing on a narrow field, barely knew anything more about the coronavirus infection than ordinary people did. Many dentists, orthopedists, gynecologists and other doctors even thought that this disease is unlikely to affect them and their work, since that’s not their specialty. In reality, the situation unfolded in a completely different way.
It quickly became clear that new hospitals and intensive care units needed doctors to work in those emergency wards, monitor patients, and, of course, treat them. In March, the Health Ministry developed interactive modules for working with coronavirus patients, and now more than half of all Russian doctors have completed this training. Due to the high social significance of such training, the process continues, and residents, students and volunteers have come to the aid of doctors.
At the same time, according to Popovich, physicians showed different levels of coping with the changes. Indeed, on top of the huge stress of inconsistentinformation about the novel coronavirus, many physicians had to face the fact that, firstly, the profession they love and in which they are successful is not in demand now, and secondly, with a change in status. For instance, the department you manage at any time can be repurposed for treating coronavirus patients.
“A lot of doctors were unable to retrain, they quit in order not to participate in professional work, and it turns out that a huge number of doctors are simply not ready for such challenges,” said the HSE expert.
For those professionals who remained in service and continue to fight for their patients on the frontlines, additional financial support is being provided. True, some mechanisms still require fine-tuning.
Money for these purposes was allocated in record time, and on April 30, the Health Ministry delivered the aid to the regions. Doctors should have received additional payments for April shifts by May 15.
But not all regions were able to quickly distribute the funds among institutions. Some of them began to calculate exactly how many hours and minutes each specialist spent fighting against Covid-19. Putin excoriated the cabinet for its lack of clarity on the payment methods.
Getting back to normal healthcare treatment plans
The work of specialized hospitals, which used to receive planned patients, has significantly changed over these months. Many hospitals donated their beds to patients with severe coronavirus infections, and now these new infectious beds need to be gradually returned to tackle cardiovascular diseases, oncology, diabetes and other diseases.
Patient organizations complained about the problems they had to face during this period with assistance to people who did not need to be treated in infectious disease wards, and experts were concerned as well. On a number of cases, however, the volume of care for patients without coronavirus, on the contrary, hadjumped. For instance, according to the Health Ministry, in the first quarter of 2020, this increase amounted to more than 50% in the field of cancer treatment.
Russia’s sanitary watchdog together with the Health Ministry is already working on ways of bringing hospitals and departments back to normal, although it is obvious that the restoration of planned medical aid is still impossible without taking into consideration the situation with the novel coronavirus, particularly because there is still no vaccine to control this disease.
"There may be another wave, which may occur somewhere around the fall, the end of October-November ... Thus, we should also bear this in mind and brace for such a development," Putin emphasized.
According to expert estimates, there is no need to increase the total number of beds in hospitals of different types or to constantly keep a reserve for infected patients.
“Keeping a bed fund based on the fact that an infectious threat is theoretically possible is very irrational, expensive and totally unjustified,” Omelyanovsky believes. “When we talk about a necessity today, we should not count only the number of state beds, we need to be able to assess existing opportunities and the needs of the system. And based on that, we should formulate the principles of managing a healthcare system in the regions.”
New objectives can also be drafted for primary healthcare, since clinics, dispensaries, medical and obstetric centers that are closest to patients, and it is here on this level that people are usually mostly dissatisfied with the healthcare system. In order to change this situation, the government was eyeing a large-scale modernization of healthcare last fall, which, however, will have to be shelved for now.
"Most likely, there will be a shift in the start of modernization of primary healthcare from July 1 to a half a year, because even implementation today will be difficult, since the mobilization of forces is aimed in the opposite direction," Murashko said at an online meeting of the State Duma Committee on Health Protection.
Currently, as the healthcare system is focused on the coronavirus threat, checkups have been suspended, and in some regions planned vaccination as well, so primary healthcare may face new challenges.
There’s room for bolstering telemedicine
Experts from the international consulting company BCG estimated that due to the pandemic, the demand for telemedicine technologies will increase significantly. On the whole, this is what happened in Russia. Many federal centers in the first quarter of 2020 completed the annual volume of telehealth consultations. It is necessary to take into account the peculiarities of Russian legislation in this field. According to law, a doctor can consult a patient only if a personal appointment has already taken place.
On the other hand, there are private services that are in great demand among Russians, as well as the experience of monitoring the status of patients at home — Moscow is using such an approach.
At the same time, according to Popovich, a number of issues related to the illegitimacy of telemedicine aid in some cases remain unresolved.
"A doctor has no right to consult from home; they must be in a medical facility. During self-isolation, even for doctors, this is very wrong," the expert noted.
Nevertheless, a number of medical institutions are already solving the teleworking problem. From the very outbreak of the epidemic, the National Medical Research Radiology Center of the Ministry of Healthcare of the Russian Federation switched all employees who are at risk to teleworking, but at the same time opened a hotline in the center where these specialists could consult cancer patients. Furthermore,the Moscow Scientific and Practical Center for Child Psychoneurology went further and organized remote rehabilitation for disabled children. This experience, of course, can be adopted and transferred to remote regions, from where it is not easy for a mother with child to travel to Moscow for regular rehabilitation sessions.
Doctor-to-doctor consultations are being held regularly,including those to solve urgent dilemmas in problematic regions, such as in the Komi and Dagestan Regions.
New aims for National Projects
No one expected the coronavirus infection pandemic, of course. In 2019, the regions gained good pace inimplementing the "Healthcare" national project. Thus, the focus on prevention, the provision of medication, the equipping of hospitals and other measures made it possible to reduce mortality rates and boost life expectancy in the country by the end of 2019. The further reduction of Russia’s mortality rates among the working-age population, drawing more doctors to hospitals and the development of children's healthcare were intended to facilitate the project’s implementation at the next stages.
Initially, the fight against infectious diseases was not included in Russia’s National Projects, because in recent decades there have been no serious outbreaks of such communicable diseases in Russia. There is the National Calendar of Preventive Vaccinations in the country, which enables the creation of sufficient individual and herd immunity to control the most common infections. But the main problem with the novel coronavirus is that no country in the world has such means of control at its disposal. All we can do so far to reduce the number of cases is to have as little as possible contact with other people and observe the rules of hygiene. Thus, since the epidemic has also disrupted the work of the nation’s immunization services, when the coronavirus tension subsides, priorities in this area may change.
However, the goals and financing of some National Projects might change as well, as the president already noted at one of the meetings. Although it is not immediately clear what to expect concerning the“Healthcare” and “Demography” National Projects so far.
"Another question is that we need to review priorities of the National Projects. And we should focus, perhaps, not on the construction of first aid stations, but, for example, on providing ambulances, training doctors, volunteers, and paramedics," Popovich believes.
At the same time, in March-April 2020, the government earmarked a total of 76.8 billion rubles ($1 bln) for setting up infectious beds, purchasing equipment,including ventilators, as well as for providing medical personnel with personal protective equipment. Experts at the Central Scientific Research Institute of Informatization and healthcare organizations note that a significant part of the costs can be considered not as budget losses, but as investment into the industry, as purchased vehicles, tomographs, analyzers, mechanical ventilation devices, oxygen stations (concentrators, ramps, and so on) will be used for several more years.
“However, given the surging importance of healthcare among society, and also taking into account the fact that part of the costs of these projects coincides with the current costs of fighting the novel coronavirus, obviously one should not expect a drastic cut in healthcare costs," the institute emphasized in an analytical report.
What lies ahead
Currently, Russia’s healthcare system is working with a margin of safety, the president stated at a meeting on the epidemiological situation. According to the health minister, two-thirds of hospital beds for coronavirus patients are now occupied — about 110,000 out of 165,000, but about 2,500 people continue to remain in intensive care. The country has ramped up the volume of testing for the novel coronavirus infection 25-fold since March, said Anna Popova, who heads the Russian sanitary watchdog.
Russia’s medical system has passed the test of the coronavirus epidemic, said Deputy Prime Minister Tatyana Golikova. However, the country may return to normal life only when the prevalence rate of Covid-19 in Russia drops to 0.5 or less. Based on data from May 24, this indicator, showing how many people a person can manage to infect before self-isolation, stands at a rate of lower than one for already a week and a half in Russia. However, as TASS calculated on the basis of data from the crisis center, in recent days it has started to grow, increasing from a minimum of 0.89 to 0.98. So, the battle rages on.