The impact of transparency constraints on the efficiency of the Russian healthcare system: systematic literature review

Abstract

There is an ongoing debate among researchers and policy-makers on how to make transparency a powerful tool of healthcare systems. This study addresses how the availability and accessibility of information about medical services to the general population affects healthcare outcomes in Russia. A systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviewing and Meta-Analysis (PRISMA) guidelines. Transparency indicators of health facilities used in the world’s most efficient healthcare systems are also reviewed. Although the increase of transparency in the Russian healthcare system is considered as a tool for improving its efficiency, very little has been done to improve the actual level of transparency. The existing institutional specifics of the Russian healthcare system impose serious restrictions on acceptable levels of transparency. In the reviewed empirical Russian studies, transparency is often viewed simplistically as either information available on the websites of medical organizations or issues related to the amount of accessible indicators of compulsory medical statistical reporting. The novelty of this study consists in (a) reviewing the most recent studies on the topic and (b) including studies in Russian in the analysis. We elaborate on general and specific policy implications for improving transparency-driven outcomes in the Russian healthcare system.

Keywords:

• Information availability
• information accessibility
• transparency
• medical organization
• healthcare facility
• website
• information disclosure
• public reporting
• healthcare outcomes
• healthcare system

JEL classification codes:

• I18
• I1
• I
• H75
• H7
• H
• H79

Introduction

Attention to transparency in healthcare has increased significantly in recent years, as transparency is critical to all aspects of healthcare systems, from the work of individual doctors, medical organizations and insurance companies to the performance of governments¹. Transparency in healthcare might be particularly prominent across the lower middle-income countries of the Global South². Here the fiscal sustainability of healthcare financing becomes more prominent in comparison to wealthy OECD countries³. For the purpose of this study, we define transparency as the availability and accessibility of information to the general population on the activities of medical organizations, health authorities, medical insurance funds and insurance companies.

Vukovic et al. analysed 62 papers published in English between 1988 and 2015 to evaluate the influence of public reporting on quality improvement, the healthcare provider’s perspective, healthcare consumers’ experience, service utilization, market share, and unintended consequences⁴. The results demonstrated that public reporting is associated with changes in medical providers’ behaviour and can affect market share. However, unintended consequences, such as “stinting on care, or directing exclusive attention to measured performance, to the detriment of important but unmeasured dimensions of care”⁴, which are driven by potential attempts of healthcare provides to achieve their “targets” without improving the care delivered to patients, should be taken into account in public data release. The results of this review provide a description of how public reporting influences patients’ opinions of healthcare provider quality and helps patients to make better choices⁵.

Similar results were obtained in the literature review by Aydin et al.⁶. The authors analysed 39 empirical studies published in English between 2010 and 2015 to demonstrate the effects of transparency on healthcare results. The findings confirmed a rise in healthcare transparency initiatives and showed mixed results regarding their influence on medical outcomes. Few articles related to the unintended consequences of public data release, which is considered to be a sign of their reduction. The results of this review can be used to understand the consequences of existing transparency efforts and to develop new transparency initiatives to improve the quality performance of medical organizations, especially in post-socialist countries².

However, the review by Metcalfe et al. (2018) revealed different results⁷. The authors analysed 12 studies published in English from the US, Canada, Korea, China, and the Netherlands. They checked how the published information about the quality and performance of medical institutions and doctors changed the behaviour of patients and healthcare providers and how it affected healthcare organization performance, healthcare consumer outcomes, and medical staff morale. The studies used for this review were published up to June 2017. The results showed that the evidence of the benefits of public performance data release are insufficient to directly influence policy and practice. More studies should be conducted to consider whether the public release of performance data can improve healthcare consumers’ experience, healthcare processes, and outcomes⁸.

Our primary research question (RQ1) is: How does the availability and accessibility of information about medical services (i.e. transparency) for the general population affect healthcare outcomes and the efficiency of the Russian healthcare system? In other words, what is the impact of transparency constraints on the performance of medical organizations and what is the impact of transparency constraints on healthcare system efficiency? In order to address RQ1, we have to answer the following questions. RQ2: Which transparency indicators are typically used in the most efficient healthcare systems? RQ3: Which indicators are typically used to measure healthcare system efficiency? RQ4: What are the policy implications for increasing the transparency of healthcare systems worldwide, and specifically for Russia?

The contribution of this study consists in: (a) reviewing the impact of transparency constraints on the efficiency of healthcare outcomes globally and across major regions, (b) revealing the most informative and useful transparency and efficiency indicators in healthcare, (c) obtaining the newest insights from empirical studies, including those in Russian, on the effect of transparency on healthcare outcomes, which was not covered by previous reviews, and (d) elaborating policy recommendations tailored to Russia and countries with similar healthcare systems.

This introduction is followed by theoretical framework, the overview of research procedure, results, policy implications, discussion, and conclusions.

Relation to the literature and the regional specifics of transparency in healthcare

Defining key terms

In this subsection, we provide working definitions for the transparency, effectiveness, and efficiency of healthcare systems.

Transparency is a public value that requires that citizens are informed about how and why decisions are made, including procedures, criteria applied by government decision makers, the evidence used to reach decisions, and results. Often transparency refers to access to information.^{9, p.2}

For the purpose of this study, we define transparency as the availability and accessibility of information to the general population. More specifically, it refers to information on the activities of institutions of the healthcare system, such as medical organizations, health authorities, federal and regional funds of compulsory medical insurance, and insurance companies. It includes: (a) the transparency of the conditions on the provision of medical care for the population, (b) the transparency of institutions (rules) on resource allocation in the healthcare system and (c) the transparency of the outcomes of healthcare system institutions.

Effectiveness is usually related to healthcare service delivery, which is based on scientific knowledge and results in improved health outcomes. Health services are provided to all who could benefit and not provided to those who do not need them (see, e.g. Araujo et al.¹⁰).

Efficiency is usually associated with healthcare services delivered in a manner, which maximizes resource use and avoids waste, including the waste of equipment, supplies, ideas, and energy. It is aimed at the greatest health improvement at the lowest cost, with the most advantageous cost-benefit (see, e.g. Araujo et al.¹⁰) According to the results of Ravaghi et al.¹¹, 41% of studies used data envelopment analysis to estimate the effectiveness of medical organizations with output variables, such as the number of inpatients, the number of ambulances, health worker costs, etc. These absolute indicators, which are measured without any relation to healthcare outcomes, provide little information on either the effectiveness or efficiency of hospitals and healthcare systems.

We consider the efficiency of healthcare systems as a synonym to efficient healthcare system outcomes or the efficient aggregate performance of medical organizations in terms of standard healthcare performance (not financial performance) using indicators, such as mortality per 1,000 surgeries, the prevalence of major diseases, etc.

Global perspective

Over the past 20 years, healthcare organizations have increased their efforts to improve the efficiency and quality of their healthcare provision^12,13. They used transparency as a means to stimulate system enhancement by providing access to information about the efficiency of medical organizations to the public. Even though there are many advocates of healthcare transparency, some studies show its risks.

For example, Canaway et al.¹⁴ noted that the public reporting system in Australia, which is a driver of transparency, has a number of flaws that are also common to other countries. First of all, there is a lack of clear aim for the information provision. There is also no consensus on who the main audience is, whether it is patients, government bodies, or other stakeholders. These fundamental issues require a solution as the way the information is presented depends on the audience¹⁴.

This leads to the problem of using the appropriate metrics for each group of stakeholders that are not only understandable, but also useful for stimulating the greater efficiency of medical organizations. The information should be presented with proper explanation of the indicators used that correspond to the needs of the main audience. Therefore, healthcare indicators should also be disclosed with cautionary and explanatory notes to the public, otherwise it brings only confusion and lessens the potential of information accessibility^15–17.

According to Baccolini et al.¹⁸, who report on healthcare performance and those who interpret it, such attention towards the explanation of the indicators is necessary due to poor health literacy. Patients are advised to become more active and engaged in their healthcare and look for the information about their medical options, thus creating a “healthcare consumerist culture” that drives clinical and hospital enhancements. However, in some cases, patients are not aware of the availability of the required information or may have issues with access to it. This problem is especially relevant to elderly patients¹⁸.

One more issue with transparency in healthcare is the discrepancies in the published data due to the poor measurement systems used or their politicization^15,16,19. For example, depending on the rating system applied, the same hospital may be considered as having both low and high levels of mortality²⁰. Such cases not only confuse stakeholders but also reduce the level of trust in the reports and value of such reports in general.

However, the discrepancies of the provided data may also appear due to medical professionals or institutions’ “gaming” it^14,17,21. For example, the doctors may avoid “difficult” patients in order to report better outcomes and obtain incentives for better results. This brings into question the validity of the information provided and raises concerns about “hidden” data, both of which hinder the improvement of the system. Such behaviour of doctors may be explained by the transparency strategy itself. Even though it is not aimed at blaming doctors for errors, but rather medical organizations, in some cases, only the individual doctors face the consequences of errors that lead to prosecution²². Hospitals, in turn, may avoid patients with serious illnesses as they negatively affect their quality performance results²¹.

Not only are individual doctors reluctant to share data, but also healthcare institutions and units within them. They are afraid of the risks and unfair changes such information may cause them^14,22.

Transparency of information did not succeed in increasing the efficiency of healthcare results without market pressure. This influenced the quality of healthcare in different ways depending on the unique features of transparency policies. However, the availability of healthcare information failed to bring necessary changes to those policies and, in some cases, the reporting of healthcare data was forbidden by the government²¹.

Summing up, the advantages of transparency initiatives for healthcare efficiency are: (1) improving the quality and consistency of healthcare provision, (2) increasing patients’ trust in healthcare providers, (3) improving healthcare outcomes and the level of patient satisfaction, and (4) informing patients about the quality of healthcare providers. On the other hand, the disadvantages include: (1) a lack of clear aims and a proper explanation of the metrics used in public reporting on the quality of healthcare providers, (2) poor health literacy of those who report on healthcare performance and those who interpret it, (3) a lack of awareness and access to the information of the performance of healthcare organizations among patients, (4) discrepancies of the published data due to the poor measurement systems used or its politicization, and (5) “gaming” healthcare data by medical professionals or institutions.

Even though these transparency constraints can be common to various national contexts, there are differences among countries that are discussed in the following sections.

The US perspective

The US healthcare system is shifting towards patient-centred processes and transparency¹⁹. For example, online review systems are being implemented and expanded¹⁹, all-payer claims data are being disclosed²¹, price transparency requirements are being established²³, transparent succession management practices are being introduced etc.²⁴. However, all these initiatives have a number of flaws. According to Kordzadeh¹⁹, only some types of healthcare institutions provide online review systems. Such systems, moreover, show inconsistent results as they use different instruments for assessing patients’ healthcare experiences, making it impossible to compare different hospitals. Han and Lee²¹ demonstrate that the disclosure of all-payer claims data fails to differentiate medical centre quality without considering market pressure. According to Berkowitz et al.²³, despite new price transparency requirements, some standard medical charges remain unclear and vary depending on the hospital and its location.

European perspective: the EU and the UK

The European and UK healthcare systems are focusing on improving the quality of healthcare provision by promoting a culture of transparency and considering resources and cost efficiency^22,25,26. However, compared to the EU countries, the UK has advanced further in fostering a culture of transparency. For example, only the UK publishes overall rankings for general practices and key healthcare institutions. Only the UK provides information on mortality rates achieved by every doctor nationally and a complex rating of the general quality of care in hospitals²⁶. However, there is little evidence of any positive impact of these transparency initiatives on healthcare outcomes. There is, however, evidence of a negative influence on some individual doctors when the cases of their medical errors were publicized²². These transparency constraints are also common to some EU countries like the Netherlands, France, and Germany²⁶.

Asian perspective: China and Japan

Chinese²⁷ and Japanese²⁸ medical systems are moving towards organizational transparency which leads to patient well-being and quality enhancement^29–31. A number of initiatives were introduced: information disclosure of medical management, treatment, healthcare quality, finances, medical errors, and patient satisfaction surveys^29–31. Despite all the benefits of transparency in healthcare, such as the improvement of patient awareness, safety, and satisfaction, several studies point out a number of constraints. Firstly, error reporting may be highly subjective, biased, and incomparable among different medical institutions³¹. Secondly, the higher the transparency, the higher the patients’ expectations about healthcare services, which diminishes the positive effects of medical treatment quality and perceived value on patients’ level of satisfaction³⁰. Thirdly, the interpretation of the data may be difficult to understand for people outside the healthcare industry²⁹.

Russian perspective

The increase of transparency in the Russian healthcare system is considered as a tool for improving its efficiency in terms of resources and clinical results. However, very few initiatives have been implemented to improve the actual level of transparency. Most studies were devoted to the analysis of the websites of medical organizations and statistical reporting that had many issues and discrepancies^32–34. Such reporting may lead to misinformation about the current state of healthcare and people’s mistrust of the medical system in general. The features and specifics of the Russian healthcare system impose some restrictions on acceptable levels of transparency^35–37. Thus, the rapid intensification of transparency may lead to negative consequences that may jeopardize the stable functioning of the healthcare system in Russia³².

Methods

Design

We employed a systematic review to identify and classify all the literature that is related to our research questions, following the PRISMA and ENTREQ reporting guidelines^38,39. This review has a results-based convergent synthesis design. This means that quantitative, qualitative, and mixed-methods research studies are found in a single search. They are then presented, described, and examined separately, and finally integrated during the data summary^40,41. In conducting this review, the steps were followed as outlined below: (1) a methodical search of literature, (2) data extraction, and (3) data integration and presentation.

Search strategy (algorithm)

We searched the following electronic databases: Scopus, Web of Science, and Russian Science Citation Index. We developed search terms for the main concepts related to the topic of our interest (e.g. transparency, information availability) and the relevant outcomes of medical organizations and healthcare systems in general (e.g. medical organizations, hospitals, healthcare system). The final search terms were: “transparency” OR “information availability” OR “information accessibility” AND “medical organization” OR “healthcare facility” OR “hospital” AND “effective care” OR “efficient care” OR “timely care” OR “healthcare outcomes” OR “surgical outcomes” OR “mortality” OR “readmission” OR “number of recoveries”. These keywords were searched for in the abstracts and/or titles of the respective articles. We focused our search on publications in English and Russian, published in 2016–2022 and in 2014–2022, respectively. The search algorithm in Russian was adjusted slightly according to the specifics of Russian terminology by, for example, adding Russian synonyms of key terms and relevant abbreviations. We also conducted a manual search of the reference lists of the research papers found in the initial search.

Search inclusion/exclusion criteria

The initial search returned 5,958 publications in English and Russian, which were transferred into Endnote where duplicates were removed; 5,109 articles remained. The titles and abstracts of these articles were scanned, and articles that did not meet the inclusion criteria were removed. Subsequently, 89 articles were left and a second full-text screen was carried out and references were examined. After that, 21 additional studies were identified and all 110 research papers were evaluated against the eligibility criteria listed below, leaving five research papers in English and 13 publications in Russian. The PRISMA diagram demonstrates our search for eligible studies (see Figure 1). Tables 1 and 2 summarize the articles in English and Russian, which were included in the analysis, respectively.

Figure 1. Flow Diagram of literature review.

Table 1. Overview of the main analysed studies published in English.

Year	Author(s)	Journal	Type of study	Sample	Main findings
2017	Canaway et al.	BMC Health Services Research	Qualitative	Purposive sample; Interviews with 41 expert informants from Australia	“Barriers [to public reporting of hospital performance data perceived by consumers, providers and purchasers] were: conceptual (unclear objective, audience and reporting framework); systems-level (including lack of consumer choice, lack of consumer and clinician involvement, jurisdictional barriers, lack of mandate for private sector reporting); technical and resource related (including data complexity, lack of data relevance consistency, rigour); and socio-cultural (including provider resistance to public reporting, poor consumer health literacy, lack of consumer empowerment).”
2019	Toffolutti & Stuckler	Health Affairs	Quantitative (multivariate regression models)	“137 English acute trusts (or hospital systems) for the period 2012–2014”	“One-point increase in the standardized openness score was associated with a 6.48 percent reduction in hospital mortality rates.”
2020	Selvaratnam et al.	An International Journal of Obstetrics & Gynaecology (BJOG)	Quantitative	“Retrospective cohort study from 2000 to 2017, a total of 1,231,415 singleton births at ≥32 weeks of gestation in Victoria Australia”	“The public reporting of a statewide fetal growth restriction (FGR) performance indicator was associated with a steeper reduction per quarter in the percentage of severe [cases of] small for gestational age (SGA) undelivered by 40 weeks of gestation, from 0.13 to 0.51% (p = .001), and a decrease in the stillbirth rate by 3.3 per 1000 births among those babies (p = .01).”
2021	Han et al.	Healthcare (Basel)	Quantitative	“Non-profit and for-profit general acute care hospitals across the states from 2011 to 2017. The total study population at the hospital level was 24,205 over the period of analysis. The average number of hospitals in a year is 3,458. This study included 50 states, the District of Columbia, and 1,933 counties in the U.S.”	“The findings in the study revealed contrasting patterns of the relationships between transparent policies and technical efficiency. We infer that specific transparency strategies may have different policy impacts on hospital efficiency. Although they pursue similar goals through public reporting, they differ in their specific public awareness and incentive designs, which may perplex patients and providers. […] When a hospital operated in a more concentrated area (higher HHIs), its technical efficiency score decreased by 0.0469.”
2021	Arkedis et al.	World Development	Mixed (RCT and interviews)	“The impact of the accountability program is assessed through randomized controlled trials (RCTs), involving 100 treatment and 100 control communities in each country.”	“Although participation in program meetings sustained in most communities, only a minority achieved tangible improvements. Few communities were able to traverse the complex causal paths from planning actions to accomplishing tangible improvements in their access to quality health care. […] Estimates of effect sizes fall short of 0.1 standard deviations across all outcomes, indicating that the differences between the treatment and control groups were small in both countries. Moreover, the 95% confidence intervals include zero in every case. Hence, we cannot reject the null hypothesis of no effect for any of the primary outcomes: utilization and content of [maternal and newborn health] MNH services, infant height-for-age and weight-for-age, or civic participation and perceptions of empowerment among recently pregnant women in communities who were offered the program.”

Table 2. Overview of the main analysed studies published in Russian (authors’ translations).

Year	Author(s)	Type of article	Sample	Main findings
2015	Gnatyuk et al.	Survey-based	Survey of 50 pharmaceutical employees in Khabarovsk	The information accumulated in the Unified Regional Information System is not accessible by patients. It does not allow compliance with the basic requirements of good pharmacy practice: orientation to the patient in order to preserve human health; promoting the rational prescription and appropriate use of medicines; orientation of each element of the pharmaceutical service to the individual. Restoring availability of information reported by licensed, and therefore conscientious participants of the pharmaceutical market, will restore public confidence in the program and ensure the quality, safety and accessibility of medical and drug care, including for certain categories of citizens who have the right to free drug provision, which has been shaken, among other things, due to improper work of the media.
2016	Murav’yova et al.	Qualitative	Websites of 79 medical organizations in Stavropol Region; survey of 148 patients and 26 healthcare employees	“Most healthcare institutions do not pay enough attention to information on transport accessibility, a list of preferential medicines, insurance medical organizations working within the framework of compulsory health insurance and regulatory organizations, there is no possibility of pre-registration for an appointment and feedback.”
2017	Garina et al.	Quantitative	“The analysis of the causes of the patients’ dissatisfaction with the medical aid based on the people’s complaints and independent assessment of the medical care quality in medical institutions found in internet sites of different levels.”	A slight increase (by 8.8% in 2016) in the number of citizens’ appeals to authorities in connection with dissatisfaction with medical care can be associated with the increased legal activity of the population and the information openness of medical organizations.
2017	Saveleva et al.	Qualitative study	“17 individual and group interviews with experts were conducted in the Republic of Tatarstan and 12 in the Republic of Mari-El (N = 59 people); 28 individual interviews and focus groups with the population were conducted in Republic of Tatarstan and 13 in Mari-El” (N = 113 people)	“New information technology with a positive impact on openness and accessibility of health care system have nevertheless some serious issues connected with organizational, infrastructural, economic, social, cultural and psychological factors: (1) insufficient information provided to the population about the state warranties of health care program; (2) poor IT support of websites representing some prevention and treatment facilities; (3) age inequality both in access to information about the services and in on-line booking of doctor’s appointments.”
2017	Khodakova & Evstaf’eva	Qualitative study content analysis of websites and their assessment by 20 experts)	N of respondents = 373; N of experts = 20; N of websites = 63; Location = Zabaykalskiy Region	Most websites of medical organizations have a formal approach to the creation, design and placement of information, which leads to a decrease in patient awareness and the availability of medical services.
2018	Polukhin	Content analysis	417 unique healthcare facility websites records from Moscow City Compulsory Medical Insurance Fund register	There is an increase in the number of medical organizations that provide on their websites the most complete information for the population about the activities of the healthcare facility in comparison with the results of previous studies, but the problem of accessible presentation of information on these sites remains.
2018	Perkhov	Quantitative	Rosstat data on financial standards of medical care in 2018–2019	The size of the coefficients used in the calculations and the stages of calculation by the Federal Fund of compulsory health insurance are not disclosed, although this is quite possible. “There are significant gaps in the compliance of the health authorities of Russian regions with the requirements of the legislation regarding the use of official websites on the Internet for the publication of open information related to their activities: • issues of quality control and safety of medical activities are not a priority in the activities of a number of regional health authorities, which contradicts Russian legislation; • the opportunity of websites, as an up-to-date information resource that ensures the openness and availability of complete and reliable information on the organization of quality assurance and control and safety of medical activities, is insufficiently used.”
2018	Bidarova	Content analysis	Efficiency indicators of the Federal Service for Surveillance in Healthcare (Roszdravnadzor, RZN) and 80 RZN’s regional divisions’ control and supervisory measures, which are posted on the official websites in Internet, as well as official data from RZN reports	39% of the regional divisions of RZN’s do not provide open data on their website on the results of control and supervisory measures, 44% of the RZN’s regional divisions give incomplete information, only 17% of the RZN’s regional divisions publish more complete information.
2018	Saveleva et al.	Mixed methods	“Semi-structured interviews and focus groups with population and healthcare workers” (N = 133; N = 1,021)	Programs of state guarantees are adopted by executive authorities and are not widely discussed, the volume and procedure for providing free medical care for citizens are not transparent. The harmonization and legitimization of social policy in health care is impossible in the absence of an open discussion of the development of health care in accordance with current and strategic plans, the inconsistency of regulatory and legal documents, regional inequality in access to medical services, the conceptualization of social justice by the subjects of political power and the population in mutually exclusive models of liberal and socialist orientation.
2019	Ekkert & Polukhin	Content analysis	417 unique healthcare facility  websites records from Moscow City Compulsory Medical Insurance Fund register	“Based on the regulatory requirements for the content of healthcare facility websites, 9 categories were formulated, including 43 conformity assessment criteria. The overall content of healthcare facility websites were evaluated as the ratio of compliant criteria to the total number of criteria.” “One fifth of health facility websites fully meet the basic requirements of regulatory legal acts.”
2019	Omelyanovskiy et al.	Content analysis of legislation	Analysis of key inefficiencies of state statistical reporting in healthcare.	Mechanisms for providing official information statistical accounting to other potential users (citizens and organizations, including for scientific purposes) are not provided for by law. Medical organizations provide low-quality reports with statistical errors and the deliberate distortion of data.
2019	Davydov	Quantitative	Patients’ survey of 42 healthcare facilities in Mordovia	The largest loss of scores occurred within the criteria “Openness and accessibility of information about medical organizations” and “Accessibility of services for people with disabilities”. To achieve the maximum assessment for the first of them is not very difficult. The minimum organizational efforts made by the Mordovian Ministry of Health and the administrations of medical organizations will make it possible to supplement the content of the websites of institutions and information stands in the premises so that they fully comply with the established requirements. The satisfaction of patients with the quality of the information provided on the activities of the medical organization is currently at a high level.
2019	Abramova et al.	Survey and content analysis	Survey (N = 2,796 respondents); сontent analysis of website www.bus.gov.ru. (77 medical organizations in the Republic of Mordovia).	Compared to 2015, the quality of information on websites increased. However, several organizations (25 out of 82; 30.5%) need to increase the transparency of and availability of information on their websites.

We included publications if: (a) they included empirical data; (b) they were peer reviewed; (c) they had extractable data related to transparency [availability, accessibility, openness] of information on healthcare services; and (d) they belonged to the “research article” or “original study” type. We excluded publications of the following types: (a) expert opinion, (b) single-case study, (c) (systematic) literature review, (d) conceptual theoretical study, (e) editorial and (f) commentary. Literature reviews, which were found during the preliminary search, were summarized in the background section.

Data extraction procedure

We extracted data from the 18 studies and categorized according to the source, country, research methods/design, data, and main findings (see Table 1). We kept categories broad due to methodological variances across and within research papers and, therefore, summary measures were not possible.

Data summary and synthesis

We combined articles to summarize descriptive statistics of the study characteristics, followed by a textual narrative synthesis. Such methods place different study types into more homogeneous subgroups. This helps in the synthesis of diverse types of evidence. It also helps to answer the research questions using different methodological approaches⁴².

Results

The most informative and useful indicators of transparency

Table 3 provides an overview of proxy-variables for “transparency” used in empirical studies related to Asia, Western Europe, and North America. Noteworthy, the transparency indicators used by the governments of the respective countries can essentially differ from their “academic analogues”.

Table 3. Overview of proxy-variables for “transparency” used in empirical studies.

Year	Author(s)	Type of study	Sample	Proxies
2014	Bucci et al.	Quantitative	222 Italian public hospitals’ websites	Patients’ right chart, waiting times, waiting lists, budget and professionals’ biosketches (from the Eurohealth Consumer Index)
2016	Jacobs & Jacobs	Quantitative	US hospitals	“It is crucial to document variables such as whether the patient was preoperatively ventilated or had an important noncardiac congenital anatomic abnormality. The lack of entry of these variables will lead to an underestimation of expected mortality.”
2016	Hota et al.	Quantitative, survey-based	“Differences between the Centers for Medicare & Medicaid Services (CMS): measured rates of safety events for Rush University Medical Center (RUMC; Chicago) and the US News & World Report (USNWR) = patient safety score”	(mainly) Patient Safety Indicators
2016	Zehir et al.	Quantitative, survey-based	“Private and public hospitals, with 351 senior and middle level managers in the province of Istanbul”, Turkey	Questions about the perception of Transparency Practices: 14 questions and 3 dimensions: Financial Reporting and Public Disclosure (3 items): Non-financial Reporting (5 items), İnformation Retrieval (6 items).
2016	Rechel et al.	Quantitative	“11 high-income countries (Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the United States)”	“Overall ratings for quality and safety of care (for every major hospital, general practice, residential care provider and domiciliary care provider); (ii) outcomes of individual health care professionals on indicators, such as mortality or other measures of performance; (iii) waiting times between referral and treatment for every major hospital; and (iv) patient experience of hospital and GP services for every provider.”
2017	Bell et al.	Quantitative, survey-based	US and Canadian physicians (N = 3,038)	Factors from items of a medical error communication survey
2017	Yan et al.	Quantitative	“Health services providers (N = 201); health service consumers (N = 384)”; Taiwan	“Disclosure of medical management; disclosure of medical treatment; disclosure of medical quality; disclosure of financial statements; disclosure of information about violations; and disclosure of insured bed ratio; and awareness and concerns.”
2018	Yang	Quantitative	2006–2007 household survey data by the World Bank; 3461 respondents from China	“Perceived clarity and perceived integrity (honesty or lack of concealment), perceived value, satisfaction perceived clarity was measured as the respondents’ evaluation of the clarity of their physicians’ explanation of diagnosis and treatment.” “Perceived integrity was measured as an ordinal variable on perceived overtreatment to identify overprescription of medicine and diagnostics, with the three levels corresponding to low, medium and high levels of perceived integrity, respectively. Perceived value is consumers’ overall assessment of the utility of a product based on perceptions of what is received and what is given. The measures of satisfaction were developed based on the American Customer Satisfaction Index.”
2019	Toffolutti & Stuckler	Quantitative (multivariate regression models)	“137 English acute trusts (or hospital systems) for the period 2012–2014”	“We used the following four questions to create the openness score: “To what extent do you agree or disagree with the following (a) “My organization encourages us to report errors, near misses or incidents” [to measure error]; (b) “We are informed about errors, near misses and incidents that happen in the organization” [to measure disclosure]; (c) “I would feel secure raising concerns about unsafe clinical practice” [to measure safety]; and (d) “If you were concerned about unsafe clinical practice, would you know how to report it?” [to measure report].”
2020	Kordzadeh	Descriptive and comparative analysis	The websites of 1,007 hospitals in the northeastern US	Provision of patient reviews about physicians on their websites, survey instruments include patient experience criteria like communication, rating of the provider, friendliness.
2020	McCarthy et al.	Quantitative	“Organizational-level data was collated for all trusts from the NHS National Staff Survey (2007–2017), NHS Acute Inpatient Survey (2004–2016) and NHS Community Mental Health Service User Survey (2007–2017)”; England	“NHS Staff Survey: Good communication between managers and staff (2008–2017) Can contribute towards improvements (2008–2017) Fairness and effectiveness of incident reporting procedures (2007–2017). HS Acute Inpatient Survey: Information about condition or treatment (2005–2016) Involvement in decisions about care and treatment (2004–2016) Ability to talk about worries and fears (2004–2016). NHS Community Mental Health Service User Survey: Listening carefully (2007–2017) Enough time to discuss needs and treatment (2007–2017) Formal meetings to review ongoing care (2007–2017) Treatment with respect and dignity (2007–2017).”
2020	Fukami et al.	Quantitative	A retrospective analysis of the reported incidents registered in one hospital; April 1, 2015 – March 31, 2019; Japan	“Reporting of incidents by medical doctors.”
2021	Han et al.	Quantitative	“Non-profit and for-profit general acute care hospitals across the US; from 2011 (N = 3,550) to 2017 (N = 3,422).”	“The availability of hospitals’ performance data was used to capture transparency. The transparent climate was calculated as a ratio of the number of hospitals that successfully reported their performance on outpatient imaging efficiency and the total number of hospitals in a county, as some healthcare organizations fail (or are unwilling) to report their performance. If a greater number of data become publicly available, then the likelihood of hospitals becoming exposed to transparency will increase.”
2021	Han and Park	Quantitative	3,221 for healthcare associated infections, 2,529 for readmissions, and 3,183 for satisfaction; the US	“The degree of accessible data on patient satisfaction all-payer claims databases (APCDs) = private health insurers, physician and hospital files, prescription drug plans and state employee health benefit programs, not to mention Medicaid.”
2021	Berkowitz et al.	Quantitative	Price transparency data from 247 publicly available hospital websites of Association of American Medical Colleges affiliated hospitals	Standard charges and usability metrics
2021	Haque et al.	Quantitative	US hospitals (N = 5,288)	(Availability of) chargemaster, charge description master, charge list, price list, standard price, or standard charges

In studies on healthcare system transparency in North America, scholars use the following indicators: the share of hospitals that successfully presented their performance on outpatient imaging effectiveness²¹, the availability of standard charges (i.e. price transparency) and usability metrics^23,43, the availability of data on medical errors⁴⁴, the availability of online patient reviews¹⁹, and the degree of accessible data on patient satisfaction²¹. According to research from Western Europe, major transparency-related indicators include, but are not limited to: the availability of a patient rights chart, waiting times, waiting lists, budgets, and professionals’ biographical sketches on healthcare facilities’ websites⁴⁵, hospital managers’ perceptions of information retrieval, non-financial reporting, financial reporting and public disclosure⁴⁶, and survey-based openness scores^22,47. Asia-related studies rely on the following indicators: the disclosure of medical management, treatment and quality, the disclosure of financial statements, the disclosure of information about violations, the disclosure of the insured bed ratio, awareness and concerns²⁹, consumer satisfaction³⁰, and the reporting of incidents by doctors³¹.

Rechel et al.²⁶ map approaches to public reporting on waiting times, patient experience, and cumulative measures of quality and safety in 11 high-income countries (Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the US). Their results suggest that most common, publicly available information refers to waiting times for hospital treatment and patient experiences. However, the latter is not usually available in terms of primary care services. Only England, out of the 11 examined countries, publishes multiple measures of overall quality and safety of care that allow the ranking of medical organizations. Likewise, the publication of information on the results of individual doctors remains rare.

In the Russian literature, typical transparency indicators refer to information accessible on healthcare facilities’ websites. In Russian public healthcare facilities, information accessibility is determined by federal legislation. However, only one fifth of healthcare facility websites fully meet the basic requirements⁴⁸. Interestingly, this result is similar to the findings by Haque et al.⁴³ who demonstrated that “most US hospitals remained noncompliant with the CMS-1694-F ruling, and compliance was associated with patient ratings, hospital type, and ownership. Even when publicly accessible, chargemasters were frequently buried within websites and difficult to use accurately”. Omelyanovsky et al.³² report that Russian medical organizations very often provide low-quality reports with statistical errors and deliberate distortions of the data. In Russia, more and diverse information can be found on the websites of private healthcare facilities⁴⁸. Notably, the state federal and regional monitoring authorities, such as the Federal Service for Surveillance in Healthcare (Roszdravnadzor), collect very detailed data on healthcare facilities’ financial and healthcare performance⁴⁹. However, much of this data is not accessible to the general public.

In Russia, the poor quality of accessible information can be partially explained by the fact that mechanisms for providing official statistical accounting information to other potential users (citizens and organizations, including for scientific purposes) are not provided for by law³². In addition, issues of quality control and the safety of medical activities have a low priority in the activities of regional health authorities in Russia⁵⁰.

Typically used healthcare system efficiency indicators

Before we proceed to our main research question, we identify how our target indicator differs among countries, especially in those with the best healthcare system outcomes.

Healthcare efficiency indicators can be divided into two groups: objective (e.g. the relative number of errors, patient waiting times) and subjective (e.g. patient satisfaction). Not surprisingly, there are differences in measuring healthcare outcomes and, therefore, healthcare effectiveness among countries. In Table 4, we summarize those related to very diverse healthcare systems across the globe, which are used in empirical studies. The noteworthy examples include studies by Arnetz et al.⁵¹, Hota et al.⁵², Jacobs and Jacobs⁵³, Raeissi et al.⁵⁴ and Weeks et al.⁵⁵. Assessing technical efficiency is one of the most popular approaches to measuring healthcare system efficiency in many countries (for example, see Han et al.²¹ in the US, Storto et al.²⁵ in 32 European countries; Jiang et al.⁵⁶ in China; and Zhang et al.⁵⁷ in Japan). Devasahay et al.⁵⁸ provide the most recent systematic review of key performance indicators used for measuring team performances in hospitals.

Table 4. Overview of proxy-variables for “healthcare system efficiency” and “healthcare outcomes” in empirical studies.

Year	Author(s)	Type of study	Sample	Proxies
2016	Weeks et al.	Quantitative	US hospitals: 1,900; 884; 1,252 and 1,243 for different diseases.	Constructed a hospital-level measure of value from a numerator composed of quality-of-care measures ([patients’] satisfaction, use of timely and effective care, and avoidance of harms) and a denominator composed of risk-adjusted 30-day episode-of-care expenditures for acute myocardial infarction.
2017	Storto et al.	Quantitative	“Healthcare systems in 32 European countries as of 2011 and 2014”	Technical efficiency with inputs and outputs as follows. “[Inputs: (1) the number of practicing medical doctors (or practicing physicians), (2) the number of practicing nurses, midwives and healthcare assistants, and (3) the number of beds available in hospitals.]” “Outputs: (1) ratio of infant mortality (between 0 and 1 year of age) to population, (2) healthy life years in absolute value at birth for both males and women, (3) life expectancy at birth in absolute value for both males and women, (4) total country population.”
2017	Jiang et al.	Quantitative	“1,105 sample hospitals which were selected from 31 provinces of China”	Technical efficiency with inputs and outputs as follows. “The number of physicians, nurses and medical technicians (people of pharmacy department, clinical laboratory, medical imaging department, radiology department and other medical auxiliary departments) and the number of actual open beds (as a proxy indicator for capital inputs) are selected as input variables, while the number of outpatient and emergency visits and inpatient days are selected as output variables.”
2018	Raeissi et al.	Quantitative	“18 hospitals linked to the Iran and Tehran Universities of Medical Sciences”	A hospital’s strengths lie in the “organizational learning–continuous improvement,” “teamwork within hospital units,” and “hospital management support for patient safety” dimensions. Dimensions including “feedback and communication concerning errors,” “communication openness,” “staffing,” and “nonpunitive response to error”.
2018	Stefko et al.	Quantitative	The period 2008 to 2015. “The total number of DMUs is 8 regions in each year (8 years). As the number of observations is only 56, which is a relatively low number, we decided to apply the DEA window analysis to expand the number of DMU units in Slovakia”	Technical efficiency: “x1- number of beds in pieces; x2 - number of medical staff in persons; x3 - number of CT devices; x4 - number of MR devices; x5 - the number of all medical devices; y1 – beds occupancy in days; y2 - average nursing time in days”
2019	Groves	Quantitative	“Data collected from two national samples of hospital organizations in the US. 142 executives completed the survey on behalf of their respective health system”	The study provides “an assessment of succession management practices and offers initial validation evidence showing their impact on hospital performance metrics. 1. Top management team engagement Performance feedback processes Talent assessment practices Leadership development culture (includes transparency) Role-based leadership development Selection and onboarding practices Succession management ROI”
2020	Arnetz et al.	Quasi- experimental	“2 weeks (10 working days) in early 2019 in a family practice clinic consisting of 25 employees, including 6 providers. The intervention team consisted of one 1.00 full-time equivalent (FTE) provider, two 1.00 FTE medical assistants (MA), and one 0.25 FTE registered nurse (RN), the existing staffing model of the clinic. The remaining five providers and their teams (N = 21 employees) comprised the reference group. US”	Cost reduction, population health, healthcare team well-being, patient experience.
2020	Selvaratnam et al.	Quantitative	“Retrospective cohort study from 2000 to 2017, a total of 1,231,415 singleton births at ≥32 weeks of gestation in Victoria Australia”	Publicly reporting a state-wide fetal growth restriction (FGR) performance indicator
2020	Badgett et al.	Quantitative	“NHS acute Trusts and respondents to the NHS Staff Surveys, 2012–2018.” (the UK)	Healthcare workforce engagement (psychological motivation, involvement in the organization, and advocacy for the organization) is associated with lower mortality.
2021	Han et al.	Quantitative	“Nonprofit and for-profit general acute care hospitals across the states from 2011 to 2017. The total study population at the hospital level was 24,205 over the period of analysis. The average number of hospitals in a year is 3,458. This study included 50 states, the District of Columbia, and 1,933 counties in the U.S.”	“When calculating the technical efficiency of hospitals, four outputs and five inputs are used. The four types of outputs in this study are: the total number of visits, inpatient days, surgery, and full-time equivalent (FTE) residents. The five types of inputs include: operating expenses (excluding payroll and benefits), the number of hospital beds, the number of Doctor of Medicine (MD) FTEs, registered nurse (RN) FTEs, and other FTEs excluding trainee FTEs.”
2017	Zhang et al.	Quantitative	“County-level data included 4 years (2008, 2010, 2012, and 2014) that covered the period before and after China’s health system reform.”	Technical efficiency with inputs and outputs as follows. “Input/output analysis. Comparisons of health spending and health outcomes between China, middle-income countries (MICs; a group of countries China belongs to at present), and the world average were used to indicate the relative productivity performance of China’s health financial input. To achieve this, we used total health expenditure (THE) per capita, life expectancy at birth, under-5 mortality rate (U5MR), and the maternal mortality rate (MMR). DEA and Malmquist Index analysis. These 2 approaches were used to measure relative efficiency and determinants of efficiency based on county-level data. Numbers of health professionals and hospital beds were employed as the health resource inputs, and numbers of outpatient visits and hospital admissions were considered health care outputs.” “Role of the PHC system. Three ratios were used to measure the performance of the PHC system in China: the proportion of primary health workers, the proportion of visits at the primary level, and the proportion of hospitalizations at the primary level.”
2017	Zhang et al.	Quantitative	“Secondary data were collected from the Ministry of Internal Affairs and Communications on 213 eligible medium-sized hospitals, each operating 100–400 beds from FY2006 to FY2011 in Japan”	Technical efficiency with inputs and outputs as follows. “Inputs: Doctors, Nurses, Other staff, Total beds, Structure area Outputs : Outpatients per day, Annual average of admissions and discharges, Emergency beds, Carryovers, Total revenue, Total expenditure”

In official reports to state authorities, Russian healthcare facility managers have to use the following indicators: fulfilment of the state order (target indicators set by the federal government for each fiscal years), number of justified complaints, satisfaction with the quality of medical care provided, the implementation of plans to achieve salary ratios, the (completeness of) coverage by doctors and nurses, proportion of visits with a preventive purpose, neonatal coverage medical supervision/patronage, vaccination coverage, average duration of stay of the inpatients, the percentage of emergency calls with a waiting time of less than 20 min, the proportion of discrepancy between the diagnosis of the emergency from the reception department of the medical organization (see, e.g. Saitgareeva et al.⁵⁹).

The effect of transparency on healthcare outcomes: global perspective

The five reviewed English-language studies, although diverse in terms of both methodology and results, are united by considering transparency and openness as drivers of healthcare system efficiency, see Table 1 for details on each study. According to a qualitative interview-based study by Canaway et al.¹⁴, a weakness of public reporting (PR) of hospital performance data perceived by consumers, providers, and purchasers in Australia consists in the fact that “the public are often not considered its major audience, resulting in information ineffectually framed to meet the objective of PR informing consumer decision-making about treatment options”. The findings of Canaway et al.¹⁴ suggest that public reporting should drive quality, safety, and performance improvements. The results of the following three quantitative studies clearly indicate the positive impact of transparency. Selvaratnam et al.⁶⁰, by performing an interrupted time-series analysis, document that, in Australia, the public reporting of a fetal-growth restriction performance indicator was associated with the improved detection of severe cases of babies small for gestational age and a decrease in the rate of stillbirths. Toffolutti and Stuckler²², using English acute care hospital data, demonstrate that a one-point increase in the standardized openness score was associated with a 6.48 percent reduction in English hospital mortality rates. Han et al. ²¹, utilising data from general acute care hospitals across the US, measure the relationships between transparent policies and technical efficiency. They recommend policymakers consider introducing competition together with the introduction of public reporting schemes to get the best outcomes from the US healthcare system. In contrast, the results of the randomized controlled trials documented by Arkedis et al.⁶¹ demonstrate that the influence of a transparency and accountability program designed to improve maternal and new-born health (MNH) outcomes in Indonesia and Tanzania was insignificant.

The effect of transparency on healthcare outcomes: Russian perspective

There is contradictory empirical evidence coming from the articles in Russian on the effects of information accessibility on patient satisfaction, which can serve as a proxy for healthcare efficiency. A survey-based study by Davydov⁶² suggests that patient satisfaction with the quality of the information provided on the healthcare facility activities in the Republic of Mordovia (East European part of Russia) is currently at a high level. In contrast, according to the results of an online survey by Garina et al.⁶³, a slight growth in the number of citizens’ appeals to authorities in connection with dissatisfaction in the provision of medical care is associated with the increased legal activity of the population and the openness of information of medical organizations in Moscow region.

Results of an interview-based study, conducted in the Republic of Tatarstan and Republic of Mari-El (both republics are located in East European part of Russia) by Savel’eva et al.⁶⁴ suggest that new information technologies have had a positive influence on openness and accessibility in the Russian healthcare system. However, there are some profound negative issues related to implementation, such as: (a) a lack of information provided to the public concerning state warranties of healthcare programs; (b) poor IT support of healthcare facility websites; and (c) age inequality in access to information about the services and in online booking of doctor’s appointments⁶⁴.

Utilising a survey of 50 pharmaceutical employees in the city of Khabarovsk (Russian Far East), Gnatyuk et al.⁶⁵ conclude that the information accumulated in the Unified Regional Information System is not accessible by patients. It does not allow for compliance with the basic requirements of good pharmacy practice, such as orientation toward the patient in order to preserve human health, promoting the rational prescription and appropriate use of medicines, and the orientation of each element of the pharmaceutical service to the individual⁶⁶. Employing content analysis of public healthcare facility websites in Stavropol region (South West of Russia), Murav’yova et al.⁶⁷ revealed common problems of these websites, which lead to inefficiencies in providing healthcare. On the one hand, there is insufficient information, which is of interest to patients, on transport accessibility, preferential medicines, health insurance companies providing compulsory medical insurance and regulatory organizations. On the other hand, the websites have poor usability due to poor design, low resolution of images, etc. These problems are caused by the formal minimalistic approach of poorly motivated website creators. These finding are supported by the results of similar studies by (a) Abramova et al. ³³, Khodakova and Evstaf’eva³⁴ and (c) Ekkert and Polukhin⁴⁸ and Polukhin³⁵, who provide evidence from Zabaykalskiy Region (Russian Far East), the Republic of Mordovia, and Moscow region, respectively. According to the results of content analysis conducted by Bidarova⁶⁸, the majority of regional divisions of the Federal Service for Surveillance in Healthcare, a federal service at the Ministry of Health that controls the quality of healthcare provision, do not provide open data on their websites on the results of control and supervisory measures.

Policy recommendations for Russia

Insights on perceived barriers for the implementation of effective public reporting are discussed by Canaway et al.¹⁴. Major barriers are conceptual (e.g. a lack of understanding of the benefits), systemic (related to deficiencies in the organization of the health system, including bureaucratization), technical and resource (e.g. lack of necessary infrastructure), and socio-cultural (for example, the illiteracy of the population on health issues, a fear of healthcare facility representatives, and the lack of complete and honest reporting on some performance indicators). The recommendations below aim at optimizing the Russian healthcare system and can be applicable in a number of other post-Soviet countries.

In order to improve information availability for the population, healthcare facility managers should receive sufficient specialized training, which would help them to optimize relevant decision-making regarding the volume and forms of public reporting and to comply with legislation^35,36,48. It would be useful to optimize the content of mandatory reporting³² by defining the necessary elements and the procedure for its public presentation. State guarantee programs, in terms of the volume and procedures for providing free medical care to the population, should be widely discussed by the expert community with the involvement of the media and, ideally, an additional open public discussion before their legislative approval^35,36. The regular reporting of the solutions provided for patient appeals on healthcare facility websites can help to improve the quality of medical care⁶³. The content of the state-owned healthcare facility websites in terms of information “richness”, functionality, and convenience for patients should be structured in a more client-oriented fashion, using modern interactive functions that allow them to get information quickly and in an understandable form³⁴. For example, for health facilities located in large cities, it would be useful to add a link to an independent resource that compares quality indicators for similar types of medical care and services. The quality of medical care can be improved when objective parameters, which are understandable to the general public, such as an independent quality assessment of medical services⁶².

In the Russian pharmaceutical market, the availability of information reported by licensed pharmaceutical market participants would restore public confidence. Providing highlights from Roszdravnadzor reports on the results of legal compliance-related inspections of pharmaceutical companies and pharmacies would ensure the quality, safety, and accessibility of drug treatment. The latter is especially important for citizens entitled to free prescriptions who have been negatively affected, among other things, by inaccurate media reports^68,69. This is in line with the general policy recommendations developed by Paschke et al.⁷⁰.

The following two conditions will determine the implementation success of the proposed policy recommendations. Firstly, it is necessary to take into account the existing barriers, mentioned above, in relation to Russian characteristics (for example, the lack of technical ability to familiarize the general public with published potentially useful information, especially among the elderly and residents of remote areas, as well as the habit of not disseminating optional information by representatives of medical organizations. Secondly, a pilot stage followed by a regulatory impact assessment is a necessary condition for the implementation of each measure.

Discussion and conclusions

There is no simple recommendation on the extent to which healthcare facilities should be transparent in order to improve healthcare outcomes. One needs to know what kind of transparency (information availability or information accessibility) positively affects healthcare system efficiency. Typically, governments regulate what kind of information should be made public. The list of indicators depends on the country. In Russia, state-owned healthcare facilities prefer to provide a minimum of information to third parties unless it is required by law. The major reason for the transparency constraint is twofold. First, they do not have enough resources to maintain high-quality access to specific information on their performance indicators. Second, facility managers try to avoid unwanted consequences from “excessive” transparency, such as patient claims with consequent audits by state authorities, and a potential decrease in bonuses.

The empirical findings related to Russia are driven by the nature of the inherited healthcare system³⁷. For example, the “imitation” of transparency through providing a lack of relevant information for patients on healthcare facility websites is caused by systemic and institutional problems, such as unclearly documented recipients of transparency policy, lack of cooperation among the stakeholders of this policy, poorly paid staff, and a high differentiation among rural and urban areas. More specific transparency constraints of Russia’s healthcare system, which negatively affect its efficiency as well, include, but are not limited to the following: there is (a) no monitoring of waiting times for planned medical care through a centralized information portal, (b) closed access to information about the allocation of compulsory insurance funds among healthcare facilities of similar types, (c) outdated procedure for adjusting planned volumes of medical care during the year, (d) difficult access to information about distribution of budget subsidies among medical organizations for the purchase of expensive medical equipment, and (e) accessing medical care efficiency without taking into account the complexity of patients’ illnesses.

Therefore, we would not recommend employing either the North American experience of medical error communication (e.g. Bell et al.⁴⁴) the Japanese experience of public reporting accidents by medical doctors (e.g. Fukami et al.³¹) or other unfavourable transparency indicators in Russia and other countries with similar cultures.

The major limitation of the Russian studies is their methodological restrictions. Typically, Russian research employs either content analysis of legislation or simple descriptions and/or comparisons of healthcare facility websites, sometimes survey-based, but without further non-parametric or parametric statistical analysis. Therefore, further research is necessary to quantify the impact on healthcare outcomes of (a) the existing transparency indicators used in Russia and (b) the major transparency indicators used in the countries with highly efficient healthcare systems.

Transparency

Declaration of funding

This article is an output of a research project implemented as part of the Basic Research Program at the National Research University Higher School of Economics.

Declaration of financial/other relationships

No potential conflict of interest was reported by the author.

Author contributions

YT was responsible for the study design and research questions definition, supervised and coordinated the joint efforts. OD collected the data. YT interpreted the results of the analysis. YT and OD drafted the manuscript. MJ revised the manuscript. All authors read and approved the final manuscript.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

None.