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Drug Policy in the Russian Federation

Open ArchivePublished:October 13, 2018DOI:https://doi.org/10.1016/j.vhri.2018.09.001

      Highlights

      • At present, the number of publications regarding the Russian healthcare system, and especially the provision of medicines, is considered insufficient. This is extremely important at a time when the Russian reimbursement system and health technology assessment are undergoing significant changes.
      • The article briefly explains country specifics, history of the Russian healthcare system, and its elements and shows the way it is developing nowadays. Conducted research provides the main issues and challenges of drug policy, which can be used when carrying out reforms.
      • The article could also be helpful when introducing improvements in countries with a healthcare system similar to that of Russia.

      ABSTRACT

      Objectives

      To describe characteristics of the drug policy in Russia in terms of health technology assessment (HTA), registries of patients, pricing of drugs, cost-containment methods, and reimbursement of drugs.

      Methods

      The legal and regulatory frameworks and the literature were reviewed to analyze several aspects of Russian healthcare: the scheme of cooperation between its structures, its levels, drug provision, issues related to HTA, the reimbursement system, pricing of medicines, and cost-containment methods.

      Results

      The Russian drug policy has improved over the last few years: HTA has been developed, rules for the pricing of drugs and cost-containment methods have been established, and registries of patients have been created. The reimbursement system in Russia is different from the ones in Western Europe and consists of a few programs: reimbursement for specific categories of citizens, vital and essential drug list, list of 24 orphan diseases, list of 7 nosologies, and other programs, depending on region. Financing for drug provision in Russia is divided into 2 levels: federal and regional. There is still a lack of transparency and equality in healthcare as well as huge differences in access to healthcare, depending on region.

      Conclusions

      The healthcare system in Russia is complicated and needs improvement. Nowadays, changes are being made; for example, there are attempts to implement HTA at federal and regional levels.

      Keywords

      Introduction

      Russia, also officially known as the Russian Federation, is the largest country in the world and is the world's ninth most populous country, which had a population of more than 144 million at the end of 2015 [

      Federal State Statistics Service. Evaluation of population as of January 1, 2016 and on average for 2015. http://www.gks.ru/free_doc/new_site/population/demo/popul2016.xls. Accessed October 19, 2017.

      ]. Expenditure on healthcare was 6.5% of the gross domestic product (ie, $957 per capita) in 2013 [
      • Britnell M.
      In Search of the Perfect Health System.
      ].
      According to the Constitution of the Russian Federation, Russia is a federal state and consists of 85 equal subjects [

      Article 65 of the Constitution of the Russian Federation. http://www.constitution.ru/10003000/10003000-4.htm. Accessed October 19, 2017.

      ]. All subjects have equal representation at the federal level—2 delegates each in the Federation Council. Local self-governments exist within their powers independently. The bodies of local self-governments are not included in the system of public authorities.
      The total expenditure of the federal budget on healthcare for 2016 amounted to $4.5 billion ($1 = R 70 [R = Russian ruble]). The budget of the Mandatory Medical Insurance Fund in 2016 was $22 billion. The regional budget was about $13.5 billion. The total health budget was about $42 billion, which was about 3.7% of Russia's gross domestic product in 2015. Healthcare expenditure per capita was about $303 [

      Skvortsova VI (Minister of Health of the Russian Federation). State program of the Russian Federation “Development of public health.” Russia, 2012.

      ].
      The purpose of this review was to analyze several aspects of the Russian healthcare system.

      Methods

      We reviewed the legal and regulatory frameworks and the literature to analyze several aspects of Russian healthcare: the scheme of cooperation between its structures, drug provision, health technology assessment (HTA), reimbursement system, pricing of drugs, and cost-containment methods.

      Results

       Healthcare System in Russia—Schemes

      According to Article 41 of the Constitution of the Russian Federation [

      Article 41 of the Constitution of the Russian Federation. http://www.constitution.ru/10003000/10003000-4.htm. Accessed October 19, 2017.

      ], everyone has the right to healthcare and medical assistance. Medical assistance in public health organizations should be provided to citizens free of charge from the appropriate budget, insurance, and other income. Financial resources in the health sector are the federal budget, the budgets of the subjects, local budgets, and mainly the Mandatory Health Insurance Fund [

      Zubets AN. Private health financing in Russia. Financial University Under the Government of the Russian Federation. http://www.fa.ru/chair/priklsoc/Pages/default.aspx. Accessed October 19, 2017.

      ].
      The Federal Compulsory Medical Insurance Fund implements the state policy in the field of compulsory medical insurance of citizens as an integral part of the state social insurance. To fulfill the established functions, the Mandatory Health Insurance Fund collects funds to ensure the financial stability of the compulsory health insurance (CHI) system. It maintains equalization of financial conditions for the use of territorial funds of compulsory medical insurance within the framework of the basic CHI program by sending these funds for the implementation of regional CHI programs in the basic benefits package. The national project “Health,” a pilot project, was launched to improve the quality of health services. The federal funds are used exclusively for the purposes determined by the legislation regulating CHI activity, in accordance with the budget approved by the federal law [

      Federal Mandatory Health Insurance Fund. Directions of activity. http://www.ffoms.ru/system-oms/about-fund/fund-activities/. Accessed October 19, 2017.

      ].
      In each subject, executive bodies of state that exercise powers in the field of health protection are formed. In turn, similar bodies are formed by the local governments of urban districts and municipalities. As per the hierarchy, these structures are subordinate to the Ministry of Health, forming the state healthcare system jointly with the state medical organizations. In addition, it can be noted that the state healthcare system is supplemented by medical organizations that are subordinate to other federal executive bodies and carry out their activities in accordance with the legislation of the Russian Federation in the field of healthcare, taking into account the specifics of the legislation regarding the provision of medical care to certain categories of citizens.

       Drug Provision

      In Russia, 21% of the health budget is spent on drugs [

      European Health Information Gateway of World Health Organization. Total pharmaceutical expenditure as % of total health expenditure. http://portal.euro.who.int/ru/indicators/hfa-indicators/hfa_578-6770-total-pharmaceutical-expenditure-as-of-total-health-expenditure/. Accessed October 19, 2017.

      ]. As part of the plan for improvement in medical care, Federal Law No. 326 of November 29, 2010, on mandatory medical insurance, and Federal Law No. 323 of November 21, 2011, on the fundamentals of healthcare for citizens [

      Federal Law No. 323-FZ of November 21, 2011 (as amended on June 26, 2016), on the fundamentals of protecting the health of citizens in the Russian Federation.

      ], were implemented. Article 80 of Federal Law No. 323 (enacted on January 1, 2012) establishes that within the framework of the program of state guarantee of free medical assistance to citizens, primary healthcare, in day care and in urgent conditions, and specialized medical care, including high-tech emergency medical care and palliative medical care under stationary conditions, are provided to citizens along with medicinal products for medical use, included in the vital and essential drug list (VEDL) in accordance with Federal Law No. 61 of April 12, 2010, on circulation of medicines [

      Federal Law No. 61-FZ of April 12, 2010 (edited on December 29, 2015), on the circulation of medicines.

      ].
      Financial provision for citizens for purchasing medicinal products for medical use is made at the expense of mandatory medical insurance, federal budget funds, and the budget of the subject. With a view to provide free medicines to the citizens by the Ministry of Health, the structure of the morbidity was analyzed and a list of medicines was compiled to ensure that priority healthcare needs for the prevention and treatment of main diseases in the structure of the morbidity are taken care of. This list was called the VEDL, and is subject to approval by the government annually.
      Government Decree No. 403 of April 26, 2012, approved the list of life-threatening and chronic progressive rare (orphan) diseases that are leading to a reduction in the life expectancy of citizens or to their disability[

      Resolution of the Government of the Russian Federation No. 403 of April 26, 2012, on the procedure for maintaining the Federal Register of persons suffering life-threatening and chronic progressing rare (orphan) diseases, leading to a reduction in the lifetime of citizens or their disabilities, and its regional segment.

      ] (hereinafter referred to as “List 24”).
      It should be noted that as of March 2017, 16 099 patients, 8 245 of whom were children, were enrolled in the Federal Register of persons suffering from life-threatening and chronic progressive rare (orphan) diseases, leading to a reduction in the life expectancy of citizens or to their disability (51.3%). In comparison, in 2013, 9278 patients with rare (orphan) diseases were registered, of whom 4316 were children. The annual increase in the number of patients in the Federal Register is on average 11% to 13%.
      The extremely high level of disability (50.2% among all patients in the Federal Register, 52.2% among children) confirms the validity of isolating these diseases into a separate group, which requires special attention of the state. The share of federal invalids (invalids of groups I and II and children with disabilities) is 84.2% for the all of diseases, and for some nosologies, it approaches 100%, but according to the current legislation, drugs for the treatment of rare (orphan) diseases from List 24 should be provided from regional budgets. As a result, there is legal imbalance and citizens with disabilities face discrimination on the basis of the disease.
      Medicinal products used for the treatment of patients with rare diseases are expensive. The average expense for financing the purchase of essential medicines and therapeutic nutrition per patient entered in the Federal Register in 2015 amounted to R 874 600, which is more than 2.5 times higher than the cost per citizen entered in the federal program register of the 7 high-cost nosologies (R 326 000). As of March 2017, the average expenditure per patient in the Federal Register is R 1.8 million. In some cases, the annual treatment cost of patients with rare (orphan) diseases (such as mucopolysaccharidosis types I, II, and VI; hemolytic-uremic syndrome; paroxysmal nocturnal hemoglobinuria; Fabry disease; and tyrosinemia) is tens of millions of rubles, which is comparable with the budget for drug provision for all population categories of some subjects.
      The total expenses for medicinal provision for citizens suffering from rare (orphan) diseases from List 24, in the period from 2012 to 2016 as a whole for the Russian Federation, increased from R 2.13 billion to R 15.5 billion.
      The aggregate deficit of regional budgets for medicines for patients with rare (orphan) diseases in 2012 was about R 1.9 billion, and in 2016 it was in the range of R 5.7 billion to R 6.8 billion.
      The share of regional budget expenditure on medicines for patients with rare (orphan) diseases from List 24 in total regional costs (also taking into account incoming federal transfers) increased from 5.9% in 2012 to 25% in 2016, and in some regions to 50%. The cost ratio not only makes the problem socially important but also jeopardizes the achievement of key indicators of the State Program for Health Development for all privileged categories of the population, including those with socially important diseases (eg, diabetes, oncological diseases, and cardiovascular diseases), and financing of medical care at the regional level as a whole [
      • Vlasov VV
      • Plavinsky SL
      Options for Drug Provision in Russia: Lessons From Countries in Europe and Around the World.
      ].
      Currently, despite the fact that in most of the subjects, the executive and legislative authorities are making efforts to provide the “rare patients” with the necessary medical care, in general it is not possible to close the existing need for treatment using the necessary amounts only from regional budgets.

       Reimbursement System

      There is no unified reimbursement system in the Western sense. There are many lists and programs at the federal and regional levels. The system is not transparent enough, and so it is difficult to use. The most important lists and programs are presented in Table 1 and are described herein.
      Table 1Russian reimbursement system
      List/programMethod
      Federal level
      Vital and essential drug listList of drugs that have a fixed price, created at the federal level
      Federal benefitsList of drugs, created at the federal level, available for some categories of citizens
      7 nosologies programFinancing of drugs included in the 7 nosologies program at the federal level
      24 orphan diseases program—diseases listList of diseases created at the federal level, but drugs financed by regions
      Reimbursement for socially significant diseasesDiseases chosen at the federal level, but financed at both regional and federal levels
      Reimbursement for specific categories of citizensSpecific categories of citizens chosen at the federal level and financed at the federal level
      Regional level
      24 orphan diseases program—drugs listDrugs determined at the regional level
      Regional programsDrugs for other diseases and for specific categories of citizens that are not included in federal programs can also be financed by regional budgets within special regional programs
      Local level
      Hospital formulariesDrugs chosen and financed at the hospital level
      Purchases of drugs through territorial fundsDrugs chosen and financed at the local level

       Federal level

       Vital and essential drug list

      The VEDL is a list of federal importance, which was created upon Decree No. 871 of August 28, 2014 [

      Resolution No. 871 of the Government of the Russian Federation of August 28, 2014, on approval of the rules for the formation of lists of medicinal products for medical use and the minimum range of medicines required for the provision of medical care.

      ]. It contains more than 500 drugs grouped according to ATX codes. The prices of these drugs are fixed, and the list is reviewed once a year.

      nosologies program list

      Drugs from this list must be included in the VEDL. These are used in hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher disease, malignant neoplasms of lymphoid, hematopoietic, and related tissue, multiple sclerosis, and after organ/tissue transplantation.

      24 orphan diseases list

      Rare (orphan) diseases are diseases that have a prevalence of not more than 10 cases per 100 000 population [

      Appendix No. 1 to Decree No. 890 of the Government of the Russian Federation of July 30, 1994, on list of population groups and categories of diseases for which outpatient treatment of medicinal products and medical products are dispensed by prescription free of charge (list of amending documents as amended by Russian Federation Government Decree No. 685 from July 10, 1995, No. 707 from September 21, 2000, and No. 103 from February 14, 2002).

      ]. In Federal Law No. 61 [

      Federal Law No. 61-FZ of April 12, 2010 (edited on December 29, 2015), on the circulation of medicines.

      ], orphan drugs are defined as drugs that are designed exclusively for the diagnosis or pathogenic treatment (treatment aimed at disease development mechanism) of rare (orphan) diseases. Orphan drugs should be funded by regional funds for persons who are not included in the list of those receiving federal benefits. Funded drugs should be on List 24, that is, the list of the following life-threatening and chronic progressive rare (orphan) diseases that lead to shortened life of citizens or to their disability (approved by Government Resolution No. 40311 of April 26, 2012): hemolytic-uremic syndrome; paroxysmal nocturnal hemoglobinuria; unspecified aplastic anemia; hereditary deficiency of factor II (fibrinogen), VII (labile), X (Stuart-Prauer); idiopathic thrombocytopenic purpura (Evans syndrome); defect in the complement system; premature puberty central origin; disorders of aromatic amino acid metabolism (classical phenylketonuria, other types of hyperphenylalaninemia); tyrosinemia; Maple syrup disease; other types of amino acid metabolism disorders of branched chain (isovaleric acidemia, methylmalonic acidemia, and propionic acidemia); violations of the fatty acid metabolism; homocystinuria; glutaric acidemia; galactosemia; other sphingolipidoses (Fabry disease, Niemann-Pick disease); mucopolysaccharidosis types I, II, and VI; acute intermittent (hepatic) porphyria; violations of copper metabolism (Wilson disease); incomplete osteogenesis; idiopathic pulmonary arterial hypertension (or primary pulmonary hypertension); and juvenile arthritis with systemic onset.

       Reimbursement for specific categories of citizens

      Drugs are fully (100%) reimbursed [

      Appendix No. 1 to Decree No. 890 of the Government of the Russian Federation of July 30, 1994, on list of population groups and categories of diseases for which outpatient treatment of medicinal products and medical products are dispensed by prescription free of charge (list of amending documents as amended by Russian Federation Government Decree No. 685 from July 10, 1995, No. 707 from September 21, 2000, and No. 103 from February 14, 2002).

      ] for adult disabled groups I and II; all invalids till the age of 18 years; disabled veterans and participants of the Great Patriotic War; family members of deceased war invalids, participants of the Great Patriotic War, and veterans; participants of the Great Patriotic War and the Blockade of Leningrad; participants of the Chernobyl failure and liquidation of its consequences; participants of the Mayak factory failure (1957) and the liquidation of its consequences; and heroes of the Soviet Union and the Russian Federation.

       Regional level

      On the basis of List 24, every region determines the drugs to be financed at its level. Given here is a list of drugs reimbursed by the Moscow City Health Department for patients living in Moscow. Drugs included in the orphan drugs regional reimbursement list could be the ones, but not those included in the VEDL. Partial funding can be obtained from regional budgets for drugs used in acute intermittent porphyria, oncological diseases, hematologic diseases, hematological malignancies, cytopenia, hereditary blood disorders, radiation sickness, leprosy, tuberculosis, severe brucellosis, system chronic severe skin disease, bronchial asthma, rheumatism and rheumatoid arthritis, systemic (acute) lupus erythematosus, Bechterew syndrome, myocardial infarction (first 6 months), condition after surgery for prosthetic heart valves, diabetes, premature sexual development, myasthenia gravis, marie cerebellar ataxia, Parkinson disease, chronic urological diseases, syphilis, glaucoma, cataracts, mental illness (disabled groups I and II as well as patients working in the medical-industrial state-owned enterprises for occupational therapy, training in new occupations, and employment in these enterprises), Addison disease, schizophrenia, and epilepsy.

       Health Technology Assessment

      In Russia, HTA began in 1997 when the Formulary Committee of the Ministry of Health developed guidelines for the assessment of medical (drug) technology and also created the appropriate standard (first released in 2001). From 2004 to 2007, the HTA procedures were stopped. Partial restoration began in 2013. An important stage was completed when the government adopted Decree No. 871 on August 28, 2014 [

      Resolution No. 871 of the Government of the Russian Federation of August 28, 2014, on approval of the rules for the formation of lists of medicinal products for medical use and the minimum range of medicines required for the provision of medical care.

      ], due to which the market access instruments, which can be used for inclusion of medical technology into VEDL, are specified and every one of them has specific weight.
      The decree was developed by the Ministry of Health with the aim to simplify and clarify the procedure for establishing lists of medicines and regulating their prices. The rules in the decree determine the manner of creating the following lists:
      • 1.
        the VEDL;
      • 2.
        minimum range of drugs for medical use and medical care;
      • 3.
        list of drugs intended for people with 7 high-cost nosologies procured at the expense of the federal budget;
      • 4.
        list of drugs for medical use, created by the decision of the commission of medical organizations, ensuring that medical care is carried out in accordance with the standards of care prescribed by doctors (medical assistants) in providing state social assistance in the form of social services.
      The VEDL is updated annually. The list of expensive medicines, the list of medicinal products for certain categories of citizens, and the minimum range of drugs are reviewed at least once in 3 years. In the process of using the Rules for the Forming of Lists of Drugs for Medical Use and the Minimum Assortment of Drugs Required for the Provision of Medical Assistance (hereinafter referred to as the “Rules”), it became necessary to refine this document.
      At present the following changes have been made to the Rules:
      • 1.
        The inclusion of a medicinal product in the list of expensive drugs and, if necessary, exclusion from it in accordance with the provisions of the decree for an alternative medicinal product should not lead to an increase in the amount of budgetary allocations provided for in the federal budget for the corresponding financial year and planning period.
      • 2.
        The list and the minimum assortment are formed by the commission established by the Ministry of Public Health to formulate lists of medicines and a minimum assortment.
      • 3.
        Changes to the lists and minimum assortment are made in accordance with the provisions of the Rules.
      • 4.
        Prompt introduction of amendments to the lists and minimum assortment is carried out in accordance with the provisions of the Rules on the basis, that are established by relevant requests of the government on considering the commission of proposals on inclusion (or exclusion) of medicinal products in the lists and minimum assortment.
      The specified changes to the Rules were approved by Government Resolution No. 700 of June 12, 2017, on amendments to Government Resolution No. 871 of August 28, 2014 [

      Resolution No. 871 of the Government of the Russian Federation of August 28, 2014, on approval of the rules for the formation of lists of medicinal products for medical use and the minimum range of medicines required for the provision of medical care.

      ].
      As mentioned earlier, the formation of the lists of medicines and the minimum assortment is carried out by a commission established by the Ministry of Health. The commission includes representatives of the Ministry of Health, the Ministry of Industry and Trade, the Ministry of Finance, the Ministry of Labor and Social Protection, the Federal Service for Supervision of Health, the Federal Service for Supervision of Consumer Rights Protection and Human Welfare, the Federal Antimonopoly Service, the Federal Medical and Biological Agency, the Federal Agency of Scientific Organizations, other federal executive bodies, federal state educational organizations of higher medical and pharmaceutical education, as well as federal state medical and pharmaceutical scientific organizations.
      Representatives of other federal bodies of executive power as well as public associations engaged in activities in the areas of public health, circulation of medicines, and protection of the rights of citizens in these areas may be invited to the meetings of the commission.
      The process of decision making on the financing of drugs may vary by region. In some regions, it is the decision of the Minister of Health of the subject, whereas in other regions decision is made on the basis of pharmacoeconomic studies and in consultation with experts on the disease (see Table 2).
      Table 2Use of pharmacoeconomics in determining reimbursement levels in Russia
      LevelDocumentInstitutionType of analysis
      FederalVital and essential drug listMinistry of HealthCEA

      BIA
      7 nosologies listMinistry of HealthCEA

      BIA
      24 orphan diseases listMinistry of HealthCEA

      BIA

      Other
      Standards of careMinistry of HealthCOI
      Clinical recommendationsChief specialists of the Ministry of HealthCEA

      COI

      Other
      RegionalDrugs in the 24 orphan diseases listRegional health departmentCEA

      BIA

      Other
      Regional programsRegional health departmentCEA

      BIA

      Other
      LocalDrug listsTerritorial health fundsABC

      VEN
      FormulariesHospitalsABC

      VEN
      BIA, budget impact analysis; CEA, cost-effectiveness analysis; COI, cost of illness; VEN, vital, essential and non-essential.

       Real-World Data

      Registers of patients are available in Russia, but they either belong to private companies (in liaison with manufacturers of drugs) or are created and maintained by government agencies. If the company that applies for reimbursement has access to the registers and can present these data in a dossier, then it helps in the evaluation of the dossier (see the “Health Technology Assessment” section).

       Cost-Containment Methods

      Physicians are not assigned with pharmaceutical budgets. There is per-capita financing in polyclinics, the size of which depends on the number of persons attached to the polyclinic. A maximum of 5 drugs can be reimbursed per visit per patient and a maximum of 10 drugs can be reimbursed per month per patient. Oncology drugs, endocrinology drugs, and some other drugs cannot be prescribed by physicians. More drugs or specialized drugs can be prescribed only after a positive opinion from the Council of Doctors [

      Order of the Ministry of Health of the Russian Federation of December 20, 2012, No. 1175, on the approval of the procedure for prescribing and prescribing medicinal products, as well as the forms of prescription forms for medicinal products, the procedure for processing these forms, their recording and storage.

      ]. Generic substitution is not mandatory; International nonproprietary name (INN) prescribing is mandatory only for prescriptions for pharmacy, and in hospitals, drugs can be prescribed by trade names. There are many documents on quality control of medical care, but the system does not operate formally. For example, insurance companies can fine healthcare organizations an amount equal to approximately 10% of the mandatory medical insurance payments, but the criteria for imposing fines are arbitrary and are not standardized.

       Pricing of Drugs

      The law that regulates the turnover of medicines is Federal Law No. 61 of April 12, 2010 (as amended on March 12, 2014) [

      Federal Law No. 61-FZ of April 12, 2010 (edited on December 29, 2015), on the circulation of medicines.

      ], on the circulation of medicines. In accordance with Article 1, the scope of this law is the relation arising in connection with the development, production, manufacturing, and preclinical and clinical research of medicines; the control of their quality, efficacy, and safety; trade with medicines; and other activities in the field of medicinal products. In accordance with Article 60 of Federal Law No. 61, the establishment of the maximum sizes of wholesale and retail markups to actual selling prices of drugs, specified by drug manufacturers for medicines included in the VEDL, is carried out by the executive authorities of the subjects on the basis of the Rules approved by Russian Federation Government Decree No. 865 of October 29, 2010.
      According to paragraph 2 of the Rules, the executive authorities of the constituent entities of the Russian Federation determine the maximum sizes of wholesale and retail markups to the actual selling prices of manufacturers for medicinal products in accordance with Methodology No. 442-a, guided by the following principles:
      • 1.
        reimbursement to wholesale trade organizations, pharmacy organizations, individual entrepreneurs, and medical organizations of economically justified costs associated with the purchase, storage, and sale of medicinal products;
      • 2.
        control on the margin of profit necessary to provide wholesale trade organizations, pharmacy organizations, individual entrepreneurs, and medical organizations with funds for servicing the attracted capital and financing other reasonable expenses;
      • 3.
        control on the structure of allowances of all taxes and other mandatory payments in accordance with the legislation.
      To calculate the price of the medicinal product, the manufacturer or wholesale intermediary transfers the commodity invoices and the price negotiation protocol to the pharmacy network or organization, which are necessary for the correct determination of the selling price of the medicinal product. Since March 1, 2016, pharmaceutical companies are compulsorily filling out a new form of the price negotiation protocol in accordance with paragraph 3 of Government Resolution No. 58 of February 3, 2016, on amending Government Resolution No. 865 of October 29, 2010, and recognizing as expired separate provisions of acts of the government.
      The development of the price policy of the pharmaceutical structure summarizes the analysis of factors that affect the organization's operations, the state of the regulatory framework, the consequences of state decisions in pricing, the price policy and strategy of competitors and consumers, and the patterns of their behavior [].

      Discussion

      For almost 20 years, since 1998, there have been many attempts to implement modern mechanisms of rational management of financial resources in the Russian healthcare system. Apart from those presented in this article, there are cost-sharing and risk-sharing schemes, solutions related to the introduction of telemedicine, public–private partnership, computerized therapy algorithms, clinical recommendations, and many more. When implementing these innovations, apart from taking advantage of foreign experience, the Russian government should take into account country specifics, history, as well as the legal and cultural environment.

      Conclusions

      The healthcare system in Russia is complicated and needs improvement. Nowadays, changes are being made; for example, there are attempts to implement HTA at federal and regional levels.

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        • Britnell M.
        In Search of the Perfect Health System.
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        Options for Drug Provision in Russia: Lessons From Countries in Europe and Around the World.
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