Society and Medicine: Evolutionary Dynamics, Financing, and Work Motivation

Martyanov I. N.¹
PhD (Medicine), Physician;
ORCID: 0000-0002-6318-0470

1LLC «Center for Allergology and Immunology», 17 Pushkin St., Anapa, Krasnodar Region, 353440, Russia

Igor N. Martyanov, e-mail: minizubr@yandex.ru

The study had no sponsorship.

The author declares no explicit or potential conflicts of interest in relation to the publication of this article.

03.06. 2026

31.07.2026

Significance.  Globally, there is a steady increase in healthcare expenditures accompanied by a simultaneous decline in the accessibility of medical care. A crisis of trust is escalating among patients, healthcare professionals, and administrative bodies. Insurance-based principles of healthcare organization and financing remain dominant in modern medicine. Efforts to identify strategies for reducing risks, lowering costs, improving accessibility, and restoring trust have proven ineffective. Research Objective. To analyze the conflict between the humanitarian mission of medicine and the economic incentives embedded in dominant «fee-for-volume» models (fee-for-service, case-based payment), and, based on this analysis, to formulate conceptual proposals for the discussion on reforming healthcare financing in Russia. Materials and Methods. Evolutionary-biological analysis, economic-behavioral analysis, sociological and historical-cultural modeling, systems analysis, comparative method. Results. The dialectical interaction of biological instincts (competition, accumulation drive) and social norms (altruism, cooperation, justice) is one of the significant factors in the development of society and models of healthcare organization. Dominant fee-for-service payment systems enter into an antagonistic contradiction with the specific humanistic nature of medicine. The fundamental conflict between market economic mechanisms and the humanistic nature of medicine distorts the professional values of physicians and undermines trust-based relationships with patients. Budgetary models, through a system of public regulation and estimated financing, create an environment conducive to the manifestation of humanism and, given adequate resource provision, demonstrate high efficiency. Conclusions.  A civilizational choice in favor of abandoning market dogmas in healthcare is necessary. A roadmap for key reform directions for Russia is proposed.

evolutionary biology, biosocial determinants, healthcare financing, fee for volume, value based payment, Semashko system, budget financing, Singapore, medical ethics, physician motivation, healthcare reform

10.29234/2308-9113-2026-14-3-1-41

1. Rayt R. Moral'noe zhivotnoe [The Moral Animal]. Moscow: AST, Neoclassic; 2020. 510 p. (In Russ.).

2. Trivers RL. The evolution of reciprocal altruism. Q Rev Biol. 1971;46(1):35-57. doi: 10.1086/406755.

3. Hamilton WD. The genetical evolution of social behaviour. J Theor Biol. 1964;7(1):1-52. doi: 10.1016/0022-5193(64)90038-4.

4. Efroimson VP. Pedagogicheskaya genetika. Rodoslovnaya al'truizma [Pedagogical Genetics. The Genealogy of Altruism]. Moscow: Ekologiya i zhizn'; 2011. 400 p. (In Russ.).

5. Walum H, Westberg L, Henningsson S, et al. Genetic variation in the vasopressin receptor 1a gene (AVPR1A) associates with pair-bonding behavior in humans. Proc Natl Acad Sci USA. 2008;105(37):14153-14156. doi: 10.1073/pnas.0803081105.

6. Kropotkin PA. Vzaimopomoshch' kak faktor evolyutsii [Mutual Aid: A Factor of Evolution]. Moscow: Red. zhurn. «Samobrazovanie»; 2011. 251 p. (In Russ.).

7. Kropotkin PA. Etika: Proiskhozhdenie i razvitie nravstvennosti. T. 1 [Ethics: Origin and Development of Morality. Vol. 1]. Petrograd; Moscow: Golos truda; 1922. 342 p. (In Russ.).

8. Wilson DS, Sober E. Reintroducing group selection to the human behavioral sciences. Behav Brain Sci. 1994;17(4):585-608. doi: 10.1017/S0140525X00036104.

9. Putnam RD. The prosperous community: Social capital and public life. Am Prospect. 1993;4(13):35-42.

10. Fukuyama F. Trust: the social virtues and the creation of prosperity. New York: Free Press; 1995. 457 p.

11. Ostrom E. Governing the commons: the evolution of institutions for collective action. Cambridge: Cambridge University Press; 1990. 280 p.

12. Golding W. Lord of the Flies. London: Faber and Faber; 1954. 248 p.

13. Dunbar RIM. The anatomy of friendship. Trends Cogn Sci. 2018;22(1):32-51.

14. Dunbar RIM. Coevolution of neocortical size, group size and language in humans. Behav Brain Sci. 1993;16(4):681-735. doi: 10.1017/S0140525X00032325.

15. Dunbar RIM. Grooming, Gossip and the Evolution of Language. Cambridge, MA: Harvard University Press; 1998. 230 p.

16. Marks K. Kapital. Kritika politicheskoy ekonomii. T. 1 [Capital. Critique of Political Economy. Vol. 1]. Moscow: Eksmo; 2021. 1200 p. (In Russ.).

17. Marks K. Kritika Gotskoy programmy [Critique of the Gotha Programme]. In: Marks K, Engel's F. Soch.: v 50 t. T. 19. 2-e izd. Moscow: Gospolitizdat; 1952. p. 9-32. (In Russ.).

18. Lenin VI. Imperializm kak vysshaya stadiya kapitalizma [Imperialism as the Highest Stage of Capitalism]. In: Poln. sobr. soch.: v 55 t. T. 27. 5-e izd. Moscow: Politizdat; 1969. p. 299-426. (In Russ.).

19. Marks K, Engel's F. Manifest Kommunisticheskoy partii [Manifesto of the Communist Party]. In: Soch.: v 50 t. T. 4. 2-e izd. Moscow: Gospolitizdat; 1955. p. 419-459. (In Russ.).

20. Khanin GI. Dinamika ekonomicheskogo razvitiya SSSR [Dynamics of the Economic Development of the USSR]. Novosibirsk: Nauka; 1991. 180 p. (In Russ.).

21. Levada YuA. Chelovek prisposoblennyy [The Adapted Man]. Monitoring obshchestvennogo mneniya: ekonomicheskie i sotsial'nye peremeny. 1999;5:7-17. (In Russ.).

22. Gudkov LD. Negativnaya identichnost': Stat'i 1997-2002 godov [Negative Identity: Articles 1997-2002]. Moscow: Novoe literaturnoe obozrenie; 2004. 816 p. (In Russ.).

23. Kahneman D, Tversky A. Prospect theory: An analysis of decision under risk. Econometrica. 1979;47(2):263-291. doi: 10.2307/1914185.

24. Saks D. Tsena tsivilizatsii [The Price of Civilization]. Transl. from Eng. Moscow: Izdatel'stvo Instituta Gaydara; 2012. 349 p. (In Russ.).

25. Lobazova OF. Aktualizatsiya pravoslavnogo asketizma v usloviyakh krizisa ekologii i morali [Actualization of Orthodox Asceticism in the Context of the Crisis of Ecology and Morality]. Mezhdunarodnyy nauchno-issledovatel'skiy zhurnal. 2021;1(103):141-144. (In Russ.).

26. Korsakova SV, Korsakova VE. Kommercializatsiya meditsiny i ee vliyanie na etiku vracha [Commercialization of medicine and its impact on medical ethics]. Nauchnoe obozrenie. Meditsinskie nauki. 2022;6:18-22. doi: 10.17513/srms.1296. (In Russ.).

27. Veselovskiy BB. Istoriya zemstva za sorok let: v 4 t. T. 3 [History of the Zemstvo for Forty Years: in 4 vol. Vol. 3]. St. Petersburg: Izd-vo O. N. Popovoy; 1911. 800 p. (In Russ.).

28. Kuz'min VYu. Vlast', obshchestvo i zemskaya meditsina (1864-1917 gg.) [Power, Society and Zemstvo Medicine (1864-1917)]. Samara: Samar. un-t; 2003. 391 p. (In Russ.).

29. Mirskiy MB. Meditsina Rossii XVI-XIX vekov [Medicine of Russia in the 16th-19th Centuries]. Moscow: Rossiyskaya politicheskaya entsiklopediya (ROSSPEN); 1996. 400 p. (In Russ.).

30. Mirskiy MB. Meditsina Drevney Rusi [Medicine of Ancient Rus]. Moscow: Rodina; 2018. 414 p. (In Russ.).

31. Egorysheva IV. Problema dostupnoy meditsinskoy pomoshchi v dorevolyutsionnoy Rossii [The problem of affordable medical care in pre-revolutionary Russia]. Problemy sotsial'noy gigieny, zdravookhraneniya i istorii meditsiny. 2013;4:52-56. (In Russ.).

32. Sukhareva IA, Pevzner DA. Platnye i besplatnye meditsinskie uslugi: istoricheskie paralleli razvitiya [Paid and free medical services: historical parallels of development]. Istoriya meditsiny. 2020;23(4):65-71. (In Russ.).

33. Omel'yanovskiy VV, Fedyaeva VK. Otsenka dolgosrochnykh izmeneniy (stsenariev) v sisteme zdravookhraneniya v usloviyakh sovremennogo tekhnologicheskogo razvitiya i tsennostno-orientirovannykh podkhodov [Assessment of long-term changes (scenarios) in the health care system in the context of modern technological development and value-based approaches]. Moscow: RANKhiGS; 2020. 52 p. (In Russ.).

34. Donabedian A. The quality of care: How can it be assessed? JAMA. 1988;260(12):1743-1748. doi: 10.1001/jama.1988.03410120089033.

35. Ulumbekova GE. Zdravookhranenie Rossii. Chto nado delat'. Sostoyanie i predlozheniya. 2019-2024 gg. [Healthcare in Russia. What needs to be done. The situation and proposals. 2019-2024]. Moscow: GEOTAR-Media; 2019. 416 p. doi: 10.33029/9704-5417-6-3-HR-2019-1-416. (In Russ.).

36. Pupo Ochoa Y. Analysis of the national health system of Cuba. RUDN J Econ. 2020;28(4):737-750. doi: 10.22363/2313-2329-2020-28-4-737-750.

37. Ulumbekova GE, Ginoyan AB, Kalashnikova AV, Al'vianskaya NV. Finansirovanie zdravookhraneniya v Rossii (2021-2024 gg.). Fakty i predlozheniya [Financing of healthcare in Russia (2021-2024). Facts and proposals]. ORGZDRAV: novosti, mneniya, obuchenie. Vestnik VShOUZ. 2019;5(4):4-19. doi: 10.24411/2411-8621-2019-14001. (In Russ.).

38. Shishkin SV. Evolyutsiya i perspektivy sistemy obyazatel'nogo meditsinskogo strakhovaniya v Rossii [Evolution and prospects of the compulsory health insurance system in Russia]. Ekonomicheskaya politika. 2023;18(1):8-33. doi: 10.18288/1994-5124-2023-1-8-33. (In Russ.).

39. OECD. Tackling Wasteful Spending on Health. Paris: OECD Publishing; 2017. doi: 10.1787/9789264266414-en.

40. Busse R, Geissler A, Quentin W, Wiley M, eds. Diagnosis-Related Groups in Europe: Moving Towards Transparency, Efficiency and Quality in Hospitals. Berkshire (UK): Open University Press, McGraw-Hill Education; 2011. 458 p.

41. Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(15):1599-1606. doi: 10.1001/jama.2013.2773.

42. Gorina AP, Inshakova NN. Sil'nye i slabye storony platnoy meditsiny [Strengths and weaknesses of paid medicine]. Nauchnyy rezul'tat. Sotsial'nye i gumanitarnye issledovaniya. 2020;6(2):105-117. (In Russ.).

43. Martyanov IN. Ekonomicheskie aspekty raboty statsionara ili ekonomicheskaya effektivnost' neeffektivnykh metodov lecheniya [Economic aspects of hospital work or the economic efficiency of inefficient treatments]. Menedzher zdravookhraneniya. 2005;1:29-32. (In Russ.).

44. Mitchell AP, Dusetzina SB, Mishra Meza A, Bach PB. Pharmaceutical industry payments and delivery of non-recommended and low value cancer drugs: population based cohort study. BMJ. 2023;383:e075512. doi: 10.1136/bmj-2023-075512.

45. Jain R. «Unnecessary hysterectomies»: are India's clinics exploiting an insurance loophole for profit? BMJ. 2024;387:q2470. doi: 10.1136/bmj.q2470.

46. Tanne JH. Covid-19: US hospitals continued to perform unnecessary surgeries during pandemic. BMJ. 2022;377:o1254. doi: 10.1136/bmj.o1254.

47. Dyer O. US obstetrician who performed unnecessary surgery is sentenced to 59 years. BMJ. 2021;373:n1317. doi: 10.1136/bmj.n1317.

48. Emrani Z, Amiresmaili M, Daroudi R, et al. Payment systems for dialysis and their effects: a scoping review. BMC Health Serv Res. 2023;23:45. doi: 10.1186/s12913-022-08974-4.

49. Smirnova VI. Byurokraticheskaya nagruzka na vrachey pervichnogo zvena [Bureaucratic burden on primary care physicians]. Zdravookhranenie. 2023;2:56-61. (In Russ.).

50. Rodin AS, Loskutova OYu, Sarbasheva PA, Grishin NS. Issledovanie konflikta interesov v meditsine po rezul'tatam oprosa vrachey [Conflict of interest in medical practice: survey of the doctors]. ORGZDRAV: novosti, mneniya, obuchenie. Vestnik VShOUZ. 2023;3:28-35. (In Russ.).

51. Aksenova EI, Besschetnova OV. Pokazateli dostupnosti i kachestva meditsinskoy pomoshchi, obespechivayushchie udovletvorennost' naseleniya meditsinskoy pomoshch'yu v razlichnykh stranakh mira. Ekspertnyy obzor [Indicators of accessibility and quality of medical care that ensure population satisfaction with medical care in different countries of the world. Expert review]. Moscow: GBU «NIIOZMM DZM»; 2021. 40 p. (In Russ.).

52. Rosenwasser TA. Un-constitutional medicare: Poisonous fruit of the poison tree. J Am Physicians Surg. 2020;25(3):73-78.