Integration of military medical services and civilian health care
as a key condition for the provision of medical care to military personnel
and the population in the event of a large-scale military conflict.

Ragozin Andrei Vasil'evich PhD in Medicine Director of the Center of Problems of Organization, Financing and Interterritorial Relations in Healthcare of the Institute of Regional Economics and Interbudget Relations, Financial University under the Government of the Russian Federation 125009, Russia, g. Moscow, ul. Tverskaya, 22B str 3, of. 308 AVRagozin@fa.ru Other publications by this author

Introduction           

During the special military operation (SVO) in Ukraine, the military medical services of law enforcement agencies faced a growing number of mine-explosive injuries (MW), the share of which in the structure of sanitary losses will increase as the supply of modern weapons to the Ukrainian regime expands, especially in the event of an escalation of the military conflict with its development into a local, regional or a large-scale war.The medical-tactical and financial-economic characteristics of the MW are due to the combined defeat of many damaging factors: explosive shock waves, primary and secondary wounding projectiles, jets of explosive gases, flames, toxic explosion products, severe psychological stress and often traumatic brain injuries, which leads to high variability of injuries, their combined and/or combined nature (often with damage to several segments of the body and/or organs), painful shock, massive blood loss and unconsciousness in a significant part of the victims, subsequently – to sepsis and a large number of other early and late complications ^[1].

           Hence, on the one hand, the dependence of mortality among the wounded with MW on the timing of emergency qualified surgical care – the so-called "golden hour" concept, during which life-saving operations limited in scope should be carried out.

             In Russian military field surgery, this approach, generally accepted today, is provided for by the concept of multi-stage surgical treatment of the wounded with a reduction in the volume of interventions in difficult conditions of the military area, and in the manuals on military field surgery of NATO countries it is called damage control surgery ^[2-6].For example, during the conflict in the Chechen Republic, it was possible to significantly reduce mortality by placing a stage of qualified surgical care (so–called medical reinforcement groups, special purpose medical detachments, an analogue in the US Army - advanced surgical groups, Forward Surgical Teams, FST) in close proximity (at a distance of 2-5 km) from the combat area, and at a distance of up to 40 km when destroying gangs in mountainous areas ^[1].

            However, unlike the local conflicts of recent decades, during the military conflict in Ukraine, the line of combat contact has reached more than a thousand kilometers – to ensure the "golden hour" for such a length, it requires the mobilization of huge forces of the military medical service into the combat zone, taking into account their regular shifts for rest and the risk of destruction by the enemy. On the other hand, the subsequent provision of assistance to the seriously injured with MW requires long-term (up to a year or more), often multi-stage treatment and rehabilitation on the basis of specialized medical organizations of the hospital base of the deep rear ^[6].Now the burden of providing a full cycle of medical care to such wounded lies with the military medical services of law enforcement agencies ^[7] - which, in the event of a mass admission of wounded, limits their ability to provide assistance in the combat zone and creates the risk of critical overload of the rear departmental hospitals up to the stop of planned hospitalizations and the inability to provide assistance to the wounded without compromising the quality of their treatment.

            The problem of overloading the military medical infrastructure is also growing due to an increase in the total number of military personnel as a result of mobilization (conscription of a significant number of reservists of older age groups and/or with poor health), as well as due to a shortage of human resources of the military medical service, which has been subjected to a large-scale reduction during the reforms of recent decades ^[7].

              In addition, the shortage of resources of the military medical service is affected by the factor of disintegration of the military medical service into separate, relatively independent departmental systems of different law enforcement agencies ^[8], as well as the so-called "peacetime effect" - the mortality of wounded at the beginning of the war, as a rule, exceeds the mortality at the end of the previous war, This is explained by the loss of trauma skills among military medical workers during periods of relative peace ^[9].At the same time, it is important to note that even in peacetime, the limited coverage area of departmental networks of military medical institutions, their remoteness from the duty station of a significant part of military personnel, the lack of highly specialized specialists in the staff, the impossibility of obtaining some types of high-tech medical care and the imperfection of the mechanism of direct financial settlements between military units and civilian medical organizations ^[10-12], often they force military personnel to receive the medical services they need, resorting to illegal practices of obtaining an MHI policy ^[13].

 So, in 2016, during the control measures, the administration of the Ivanovo region identified 2,187 military personnel, and the administration of the Ryazan region identified 2,493 people.

  Thus, in 2016, in the territories of only two subjects of the Russian Federation, during random inspections, the number of military personnel and persons equated to them who were forced to illegally obtain an MHI policy amounted to 5,361 people – which indicates an unfavorable situation with the availability of medical care within the military departmental system^[1].Organizational, financial and economic integration of the military medical service and civilian healthcare as an alternative approach to providing medical care to troops and the population in a large-scale military conflict.

 The shortage of resources of the military medical service is inevitable in the conditions of any large-scale military conflict. Probably, this was first postulated by N.I.Pirogov, who, as the chief surgeon of the army, was engaged in organizing assistance to the wounded in four wars — in the Caucasus, Crimean 1853-1856, Franco-Prussian 1871-1872 and Balkan 1875-1877. "War is a traumatic epidemic. As with large epidemics there is always a shortage of doctors, so during large wars there is always a shortage of them. What all governments did not do to prevent this shortcoming, everything turned out to be unreliable on occasion. Neither huge military medical institutions, nor reserves of private doctors, nor the invitation of foreigners replenish this defect in wartime" ^[14]. Therefore, N.I. Pirogov considered the integration of the military medical service with civilian health care (mainly private in the nineteenth century), which should be "always ready to fill in the gaps, temporary and local deficits of the military administration" as a key condition for effective assistance to wounded and sick servicemen during the wars ^[15].

  In the book "Military medicine and private assistance in the theater of war in Bulgaria and in the rear of the active army in 1877-1878," N.I.Pirogov outlined the basic principles of such integration, many of which have not lost their relevance yet - but, unfortunately, are practically not used today in the Russian Federation:1. A clear division of labor (functions and responsibilities) between civilian and military medicine, which should not act as competing alternatives, but complement each other both in peacetime and in wartime.

 2.                 

The principle of "two keys" in management: the civil health administration controls the implementation of medical standards and treatment standards by the military medical service. In turn, in wartime, organizational and administrative decisions of the military medical administration are mandatory for civilian medicine.3.                 

The planned nature of the interaction and joint use of the resources of civil health and the military department — including the early development of common plans and the conclusion of agreements before the outbreak of war.4.                 

The exchange of information between the administration of civil and military medical infrastructure is, according to N.I. Pirogov, "the most frank presentation of the needs and means available to both institutions."5.                 

Mobilization readiness of civil health care, which "should be provided not only in wartime, but also in peacetime with mobile premises of various kinds, always ready in case of war."6. A uniform approach to the financial and economic provision of medical care for wounded and sick servicemen: civilian healthcare should "accurately determine the standard of patient care, the size and quality of its funds, most similar to the norm of the military department."

^[15]There is reason to believe that the success of Soviet military medicine during the two major wars — civil and World War II — was due precisely to the implementation of these principles of integration of civil and military medicine.

            The maximum level of such integration (up to the organizational and administrative merger) took place in the period of 1918 -1929, during the most difficult years of the civil war, foreign military intervention and numerous epidemics - when the Main Military Sanitary Department (GVSU) The Red Army entered the People's Commissariat of Health of the RSFSR as an independent department. Up until 1929 (when the GVSU, renamed the Military Sanitary Department of the Red Army, was transferred from the People's Commissar of Health to full subordination to the People's Commissar for Military and Naval Affairs), military medicine in the USSR worked and developed in a system of double subordination in full accordance with the views of N.I.Pirogov. On the one hand, the GVSU was subordinate to the People's Commissar of Health (the head of the GVSU was also the deputy People's Commissar of Health), on the other hand, it carried out the orders of the People's Commissar for Military Affairs and directed the military sanitary services of all types of troops and power commissariats ^[16,17], thereby avoiding the disintegration of military medicine between different departments. This approach made it possible to use the resources of both civilian and military healthcare most effectively for medical support of the active army, the fight against epidemics ^[18].The Soviet military medical service also faced a catastrophic shortage of resources in the frontline and an overload of military hospitals in the rear with wounded in the first months of the Great Patriotic War ^[19].

  The problem was solved by the resolution of the State Defense Committee No. GKO-701ss of September 22, 1941 "On improving medical care for wounded soldiers and commanders of the Red Army", which was built on the above principles of integration of military and civilian health care by N.I.Pirogov:

 1.                  The integration of military and civilian medicine into a single centrally managed system with the division of labor and the principle of "two keys" in management: responsibility for helping the wounded on the battlefield and in frontline areas was assigned to the Main Military Sanitary Department of the People's Commissariat of Defense of the USSR, and for subsequent staged treatment at the hospital base of the rear - to the People's Commissariat of Health The USSR, which was subordinated to the system of so-called evacuation hospitals. At the same time, the Main Military Sanitary Department was entrusted with the duty to monitor the work of evacuation hospitals of the People's Commissariat of Health of the USSR.2.                 

Inclusion in the system of evacuation hospitals of rehabilitation infrastructure — sanatoriums and rest homes of the VTSPS — with their subordination to the People's Commissariat of Health of the USSR.3. Centralized financing and material supply of functionally integrated military and civilian medical infrastructure (evacuation hospital systems)

according to uniform standards: evacuation hospitals subordinate to the People's Commissariat of Health of the USSR received material and monetary resources from the People's Commissariat of Defense of the USSR according to the norms and procedures established in the Red Army.Thus, the success of Soviet military medicine during the Great Patriotic War (of the hospitalized 22 million soldiers and officers, 17 million people were returned to service, including 72.3% of the wounded and 90.6% of the sick ^[20]) was achieved thanks to the integration of military and civilian medicine into a single centrally controlled system, unification into a single technological the cycle of treatment and rehabilitation and their uniform centralized financial and economic support according to uniform standards, which equally guaranteed coverage of the costs of treatment and rehabilitation of the wounded, regardless of which medical institutions and in which region of the country they were.

 Finally, today the integration of civilian and military medical infrastructure in the event of a large—scale military conflict is the cornerstone of NATO's military medical doctrine - its chapters D (Medical support to major combat operations) and E (Medical support to stabilization and reconstruction) postulate:

 "1.11. Large-scale combat operations are difficult for medical support due to factors such as the number of military elements and troops involved, due to the potential impact on the civilian population and infrastructure.

  Military medical services may not be able to cope with the expected number of accidents, while civilian medical infrastructure will have difficulty meeting the needs of the civilian population, especially in densely populated areas. The resilience required to manage such a scenario depends on political will and action, robust contingency planning, maintenance of appropriate infrastructure, comprehensive civil-military cooperation and mutual support of all nations and organizations involved.1.13. In addition, a major conflict can have a significant impact on local civilian health systems, services, infrastructure and talents, and many facilities and services can be destroyed or rendered useless.

  In these circumstances, local civilian authorities may request medical assistance from NATO commanders.1.14. Reconstruction should be aimed at stabilization by creating or maintaining the legitimacy of the Government, ensuring the possibility of the return of displaced persons, facilitating the return to normal life.

  Security and the provision of socially important and social goods and services are interdependent; security is needed to ensure the provision of services — and progress in restoring services is necessary to maintain security.1.15.

  Restoring medical services to the population is primarily the responsibility of civil services — military forces are likely to contribute to creating a safe environment.  However, in some circumstances, such as emergencies, the armed forces may be the only available assets to begin restoring the provision of basic medical services to the population. In such cases, military units should carry out such tasks, but with a clear intention to transfer them to local, regional and governmental organizations and institutions as soon as possible.1.16. NATO medical units can play a role in providing medical support to other NATO security elements contributing to stabilization and recovery.

  In addition, NATO medical units can assist local authorities in restoring and improving local health services, as a last resort — temporarily eliminate gaps in the provision of medical services until local authorities can do it. There are a number of medical support activities in which the armed forces can participate — from direct medical care to public health activities. Any provision of medical care to the local population by NATO forces should be planned in accordance with local standards"^[2].

  The situation with the integration of military and civilian medical infrastructure in the Russian Federation today can hardly be called prosperous. During the reforms of the 1990s, the "mobilization" model of Soviet healthcare was destroyed — military and civilian medicine are developing largely in isolation from each other, the formalized division of functions and responsibilities between civilian and military medicine, the planned nature of their interaction and the sharing of resources both in peacetime and in wartime seems underdeveloped. The principle of "two keys" in management is out of the question, the exchange of information between the administration of civil and military medical infrastructure is difficult even at the level of the exchange of medical statistics. The COVID-19 pandemic clearly demonstrated the low mobilization readiness of the civil healthcare of the Russian Federation for the mass admission of patients — when, due to a shortage of resources, the provision of planned and preventive care to the population had to be stopped^[3].The difference between the financing mechanisms of military and civilian medicine — the first is financed by budget estimates, the second provides for the payment of medical services by insurance and budgetary mechanisms — is such that their funding standards cannot even be compared with each other.

            Finally, unlike the NATO countries, until recently the Russian Federation did not have a military medical doctrine that would allow, among other things, to define the principles and model approaches for integrating military and civilian healthcare in the event of a large-scale military conflict.Discussion

 Attempts made until recently to integrate military medicine with civilian medicine, or at least to protect the rights of military personnel to medical care by including them in the compulsory medical insurance system, faced problems of interdepartmental interaction caused by both unresolved issues of integration of military and civilian medicine in peacetime and wartime, and the need to find funds to pay compulsory medical insurance contributions for military personnel.

The first attempt was made in 1997, when the Government of the Russian Federation adopted Resolution No. 1387 of November 5, 1997 "On measures for the stabilization and development of healthcare and medical science in the Russian Federation", which provided for the integration of departmental medical institutions into the general healthcare system on a single regulatory framework, taking into account their industry characteristics and location^[4].

  In this part of the tasks, this resolution has not been fulfilled.The next attempt at integration was made by the Ministry of Health of the Russian Federation in 2014 in the draft "Strategy for the development of Healthcare of the Russian Federation for the long-term period 2015-2030", which provided for the unification of all departmental medical systems into a single national health system (draft of the Ministry of Health of the Russian Federation, 2014). This proposal was not elaborated in detail (remaining a declaration) and did not included in the "Strategy for the development of healthcare in the Russian Federation for the period up to 2025", approved by Decree 

 Of the President of the Russian Federation dated June 6, 2019 N 254.Finally, another attempt to integrate military and civilian medicine was made in 2016 by the Ministry of Health of the Russian Federation and the Ministry of Finance of the Russian Federation, which proposed to include military personnel and law enforcement officers equated to them in the organization of medical care (with the introduction of contributions to the FFOMS budget for them), making military hospitals accessible to the population for treatment by CHI.

              The available information suggests that the main reason for this initiative was an increase in the income of the CHI system. "Introduction of insurance premiums by military personnel... it gives us the opportunity to include various redistributive mechanisms. Since these are, as a rule, young and healthy men, they do not require such an index of medical care as the elderly, so it is beneficial for our system, and we will not object to this," said Minister of Health V.I.Skvortsova. "This will require additional resources — redistribution from the power unit for transfer to the Mandatory Medical Insurance Fund, but ultimately it will equalize our citizens in receiving medical care," Finance Minister A.G.Siluanov supported the idea, who also proposed to reduce military medical institutions — leaving only a few secret institutions in their current status, taking measures to strengthen their financial and economic discipline, arguing that "the cost of services in a military medical institution is often three or more times more expensive than in a conventional medical institution"^[5]. These proposals were blocked by the heads of law enforcement agencies.From the authors' point of view, the reason for the failure of integration attempts is that they did not take into account the specifics of military medicine and the principles of its integration with civilian health care, repeatedly tested by the USSR's experience in medical support of large—scale military conflicts.

  In addition, in 1998, Federal Law No. 76 "On the status of military personnel" was adopted, which guaranteed the right to receive medical care in military medical organizations and to sanatorium treatment not only for active military personnel, but also for a number of categories of those discharged from military service, as well as their family members^[6] - thereby depriving the army departmental medical infrastructure could become a source of social conflict.Therefore, the key obstacles to effective integration between the military medical service and civil healthcare, the organization of their effective interaction in peacetime and mobilization readiness for epidemics, disasters and wars are the following:

 1.                  The absence of a modern military medical doctrine as an integral component of the Military Doctrine of the Russian Federation^[7], which should set out the basic principles and model approaches for the integration of the military medical service and civilian healthcare, their interaction in peacetime and wartime - including mobilization readiness for a large-scale military conflict.2. The difference in the methods of financing military and civilian medical infrastructure: the military has largely retained the principles of Soviet estimated budget financing, and the main channel for financing civilian medical infrastructure is the compulsory medical insurance, the rights to which military personnel are deprived — Federal Law "On Compulsory Medical Insurance in the Russian Federation" dated 29.11.2010 N 326—FZ.

Within the framework of this law, mobilized reservists should also be excluded from the compulsory medical insurance.3.                 

During the reforms of the 1990s, the unified technological cycle of medical care was disintegrated: financing of medical rehabilitation and long-term care services, contrary to the experience of developed countries (where these tasks are assigned to the health system), was transferred to the Social Insurance Fund, which creates a number of problems of interdepartmental interaction and interferes with the continuity, continuity and integrity of care for the wounded. The preservation of this provision is provided for in the framework of the merger of the FSS and the FIU into the Pension and Social Insurance Fund of the Russian Federation^[8].4.                 

  The inclusion of military personnel in the compulsory health insurance system requires the search for additional or alternative insurance sources of income of the Federal Social Insurance Fund in the face of a growing federal budget deficit, a chronic shortage of funds from the subjects of the Federation for compulsory health insurance of the unemployed population and the need to reduce the fiscal burden on employers in the conditions of economic sanctions imposed against the Russian Federation.5.                 

Taking into account the unpredictable increase in the number of wounded in the event of an escalation of the military conflict, the high cost of their treatment and rehabilitation (and in the future – the cost of medical care for the disabled), it is necessary to modernize the income system of the CHI, which should cover the growing costs of the health system with minimal burden on the budget and the economy.The solution proposed by the authors:

1.                 

  It is necessary to develop a modern military medical doctrine, the principles of which in relation to the integration of civil and military medical infrastructure are proposed to be developed, taking as a basis the approaches outlined by N.I.Pirogov in the work "Military medical care and private assistance in the theater of war in Bulgaria and in the rear of the active army in 1877-1878."2.                 

Do not exclude those being mobilized from the compulsory health insurance system by including military personnel and categories of persons equated to them in the organization of medical care — in case of medical care that cannot be provided by military medical institutions due to their overload, remoteness or lack of the necessary specialists - just as this issue has already been resolved with respect to some categories of military pensioners.3.                 

As part of the merger of the FSS and the FIU — to exclude from the functions of the created Pension and Social Insurance Fund of the Russian Federation the organization of events in the field of medical rehabilitation and long-term care services, transferring these functions to the FFOMS.4.                 

To ensure the inclusion of military personnel in the compulsory medical insurance and the growing costs of the healthcare system in the conditions of a military conflict, while reducing the burden on the budget and the economy by modernizing the FFOMS income system — replacing the compulsory medical insurance contributions paid by employers (for employees) and the subjects of the Federation (for the unemployed population) with a universal compulsory medical insurance contribution, automatically withheld at the same rate for all legal and individuals are charged from all non—cash transactions - thereby financing additional medical guarantees for military personnel by leveling the "stowaway effect" in the MHI system ^[21].The last proposal is aimed at solving the key problem of the compulsory health insurance system — the problem of the "stowaway": compulsory health insurance contributions for a significant part of economically active citizens (workers of the shadow economy, informally employed, as well as non-employed citizens living on income from capital, rent and criminal activity) are not paid at all or are regressive (disproportionate to their actual income), while "stowaways" cannot be deprived of guarantees of public medical care.

             In the situation of Russia's large-scale shadow economy (39.3% of GDP — according to the Association of Chartered Certified Accountants, 2017) and informal employment (35.9% of the working population - the International Labor Organization, 2018), the "stowaway problem" leads to a chronic deficit of the compulsory health insurance system, the balance of which has to be maintained by growing expenditures of the budget system, as well as a decrease in accessibility of medical guarantees to the population: "optimization" of hospitals, low salaries of medical workers, imposition by state medical organizations of paid services that duplicate state guarantees.

            An analysis of available sources shows that the most promising solution to the "stowaway problem" in the compulsory health insurance system may be the idea of the well-known researcher of the shadow economy, American Professor E.Feige, who proposed replacing social contributions from salaries (including health insurance of the population)  a universal tax withheld at the same rate for all legal entities and individuals from all non–cash transactions, as well as from operations for withdrawing and depositing cash to a non-cash account - the so-called Automated Payment Transaction tax, APT. The available data on the theoretical justification of this tax and a fairly successful pilot 14-year project to use its prototype of the CPMF tax to finance healthcare in Brazil ^[22-24] suggest that such an approach, firstly, will minimize the evasion of compulsory health insurance contributions and with a minimum of costs for their administration to attract solidarity the shadow and offshore economy, informally employed and self-employed, as well as those who live on capital income, rent and criminal income, are considered "unemployed" and do not pay compulsory medical insurance contributions, but enjoy medical guarantees without restrictions.Secondly, the inability to evade withholding the contribution (tax) from each transaction will minimize the so-called tax gap (concealment, undercharging, non-payment, inability to recover) in the collection of compulsory health insurance contributions from the transparent sector of the economy.

 Thirdly, the maximum possible tax base, the impossibility of evasion and the minimum costs of administration allow you to reduce the tax rate to a minimum.

  A retrospective approximate calculation of the APT contribution rate for the complete replacement of the FFOMS income system in 2020 (when, according to the Bank of Russia, non-cash payments in the amount of 1657.6 trillion rubles were made through systemically significant payment systems of the Russian Federation.^[25], and the FFOMS budget was executed on revenues in the amount of 2.4 trillion. rubles ^[26]) shows that in 2020, the entire income system of the CHI system could be replaced by one universal contribution APT with a rate of 0.14% ^[27].Thus, additional resources for the inclusion of military personnel in the compulsory health insurance system can be attracted not from the budget system (on the contrary, the load of transfers of the Federal Social Insurance Fund will be removed from the federal budget, and the obligation to pay compulsory health insurance contributions for the unemployed population will be removed from the subjects of the Federation) and not due to the growth of the fiscal burden on employers of the transparent sector (on the contrary, they will be removed the obligation to pay compulsory medical insurance contributions for employees), and by redistributing the fiscal burden on those who currently do not pay compulsory medical insurance contributions — that is, by restoring social solidarity and leveling the "stowaway problem".

             In turn, ensuring the balance of the compulsory health insurance system not by large-scale expenditures of the federal budget and the budgets of the constituent entities of the Federation, but by insurance premiums jointly paid by the entire economy and all economically active population will allow fulfilling the repeated demands of the President of the Russian Federation to transfer to the insurance principles of the compulsory health insurance system and increase its financial stability^{[9],[10],[11]}.

 ^[1]Conclusion on the draft federal law "On the Budget of the Federal Compulsory Medical Insurance Fund for 2017 and for the Planning Period of 2018 and 2019" (approved by the Board of the Accounts Chamber of the Russian Federation, Protocol No. 58K of November 7, 2016).

Available: https://ach.gov.ru/upload/pdf/audit/1d6aea525b8cd34e06f8c2f5a4973b01.doc .

^[2] NATO standard AJP-4.10 Implemented joint doctrine for medical support Edition C Version 1 with UK national elements. September 2019.URL: https://www.coemed.org/files/stanags/01_AJP/AJP-4.10_EDC_V1_E_2228.pdf.

^[3]Letter of the Ministry of Health of Russia, FFOMS dated 03/25/2020 N 11-8/and/2-3524/4059/30/ and "On the provision of medical care in the case of a disease caused by COVID–19". Available: http://www.consultant.ru/document/cons_doc_LAW_348527/

^[4]The Government of the Russian Federation No. 1387 of November 5, 1997 "On measures for the stabilization and development of healthcare and medical science in the Russian Federation". Available: https://base .garant.ru/12104340/.

^[5]Civilian medicine dreams of the military. Kommersant, 11.11.2016 Available:https://www.kommersant.ru/doc/3138326.

^[6]Federal Law "On the status of military personnel" dated 27.05.1998 N 76-FZ. Available: http://www.consultant.ru/document/cons_doc_LAW_18853 /.

^[7]Military doctrine of the Russian Federation. Approved by the President of the Russian Federation on 25.12.2014 No. Pr-2976. The guarantor. Available: https://base .garant.ru/70830556/.

^[8]Federal Law No. 236-FZ of 14.07.2022 "On the Pension and Social Insurance Fund of the Russian Federation". Available: http://www.consultant.ru/document/cons_doc_LAW_421786 /.

^[9]List of instructions for the implementation of the President's Address to the Federal Assembly dated 27.12.2013 No. Pr-3086, item 1.5. Available: http://kremlin.ru/acts/assignments/orders/20004 .  

^[10]List of instructions for the implementation of the President's Address to the Federal Assembly dated 05.12.2014 No. Pr-2821 item 14. Available: http://www.kremlin.ru/acts/assignments/orders/47182/print .

^[11]The list of instructions on improving the system of compulsory medical insurance, approved by the President of the Russian Federation No. Pr-2072, item 2, dated December 12, 2020, is available: http://www.kremlin.ru/acts/assignments/orders/64656 .