Rationing of medical care: how medical care to be distributed in conditions of limited resources

Background. Rationing of health care—restricting patients' access to potentially beneficial health care interventions through non-market instruments—is a natural feature of all health care systems as they operate under resource constraints. The purpose of this study is to characterize rationing practices and the attitude of doctors themselves to it, with an emphasis on comparing Russia and the United States and on changes in the perception of rationing during the COVID-19 pandemic. Methods. We conducted a bibliometric analysis of publications in the medical scientific literature since 1989 on the issue of rationing of medical care. To characterize rationing practices in Russia and the United States and the attitudes of doctors towards them, we used data from published studies and data from semi-structured in-depth interviews with 28 Russian doctors. Results. Despite the increasing frequency of publications related to the topic of resource allocation over the past 20 years, studies using the term "rationing" are rare. Both Russia and the USA have practices of explicit and implicit rationing. In Russia they are more diverse and widespread. In both countries, doctors prefer implicit rationing and do not want open discussion of these issues. The practice of rationing is institutionalized. In Russian medical organizations its most common form is a chain of permissions for the use of resources. But most doctors believe they are not rationing care. The pandemic briefly brought the topic of rationing into the public sphere, but then its discussion was limited. The probable reason is that medical practice during the pandemic was carried out within the previous legal framework. Professional organizations have developed several recommendations for rationing, but their usefulness and level of acceptance by professionals and the public is unclear. Conclusions The transition from implicit to explicit rationing is extremely difficult, but is necessary to ensure equitable patient access to scarce medical resources and the effective functioning of health care systems. A major barrier to the explicit and informed use of rationing instrument is the limited public acceptance of it and the reluctance of professional communities to make public decisions that maximize public benefit by prioritizing access to effective interventions.