case study outsourcing of hospital services

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Hospital outsourcing: the opportunities and challenges.

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Jacob Kupietzky is President of  HealthCare Transformation , a company dedicated to providing hospitals with experienced interim executives. 

So you want to run a hospital. How would you do it?

If you take the traditional route, you’d operate it like a brick-and-mortar business, a self-enclosed unit where a team of executives managed the entire facility, from clinical care to nutrition to transportation to the gift shop out front. You’d have complete control and autonomy but also complete liability. Plus it might be hard (and expensive!) to build up your resources and skill providers to create a best-in-class facility.

But today, we live in a world of specialists, people with particular expertise in specific services. What if you ran your hospital less like a big box business and more like a shopping mall? In this kind of model, you could attract only the best offerings, with full authority over which brands provide which services. You could focus on what you’re good at — operating suites and ICUs — and outsourcing the rest. Maybe Walgreens could manage the pharmacy needs, Wolfgang Puck Catering could manage non-patient food needs, Hertz could take over non-emergency transportation and ADT could manage security.

By adopting a distributed model, focusing on what you do best and coordinating the rest, you could still provide a world-class experience while limiting your liability. Plus, those third-party vendors would compete to operate in your facility, helping you keep costs down.

This future of specialist-run healthcare isn’t some distant vision. It’s here now. According to market research from 2019 (paywall) , the healthcare outsourcing market is projected to reach nearly $450 billion worldwide by 2023. And a recent survey of more than 500 hospitals and inpatient organizations found that 90% of healthcare executives are exploring cost savings through relationships with third-party vendors.

The Business Case For Outsourcing

Part of this fundamental shift in how we look at hospital care is economic. Even before the pandemic, hospitals were struggling financially. Prestigious facilities like the MD Anderson Cancer Center had reported operating losses of hundreds of millions of dollars , largely due to shrinking patient admissions and inadequate workforce management. One 2019 report found that hospitals across the country were experiencing a 21.3% decline in operating margins. This crisis was only made worse during the pandemic. The American Hospital Association estimated that more than one-third of hospitals will end 2021 with negative margins. As bad as this might sound, the outlook for rural hospitals is even worse. More than 100 rural hospitals have closed since 2013, with closures hitting a record high in 2020.

As a result, many healthcare facilities are looking to save money by turning to more of a distributed model, with some success. For example, Sheridan Healthcare outsourced its anesthesia and perioperative services and reduced the time required for operating room turnover by 35% (registration required) , allowing the organization to add 250 extra patient cases each month. When Georgia Regents Health System partnered with Philips Healthcare to manage radiology and cardiology services, it saw increases in the number of vascular and interventional radiology scans, MRIs, ultrasounds and CT scans, resulting in $7 million in savings . And after deciding to outsource environmental services, one rural hospital in Arcadia, Florida, saw increased turnaround times for its Med Surg and ICU units and a 10% annual savings in departmental spending.

The Human Case For Outsourcing

Of course, the most important benefit to outsourcing can be higher-quality care and better patient outcomes. This is accomplished primarily in two ways:

• Allocate resources away from areas with less specialized expertise. Healthcare facilities develop proficiency in particular areas for a variety of reasons, such as organizational mission, community needs, talent pool to recruit from, competitive landscape or availability of financial resources. Yet that doesn’t mean other areas can be ignored. By outsourcing areas a facility lacks expertise in, they can still provide exceptional service and do so more efficiently (often with cost savings).

• Allocate resources toward areas with more specialized expertise. Hospitals that outsource can free up their own internal staff and let them better focus on what they do best, including growing service lines, training and talent development. Those cost and personnel savings can even create better outcomes in those specialized areas than they would otherwise achieve.

This is particularly important in rural facilities, which often don’t have the resources to fund best-in-class services. Academic Medical Centers (AMC), on the other hand, are highly funded and can provide unparalleled care and rely on philanthropy to close gaps. Imagine if a rural hospital could outsource emergency care to the closest AMC. The AMC could expand training opportunities for its students and clinicians while supporting a facility that can’t source it themselves thereby creating a “win-win.” This kind of real medical partnership could make an enormous difference in the lives of the nearly 20% of Americans served by small-town hospitals.

There are clear benefits to outsourcing and leveraging external partners who are experts in their fields. But outsourcing isn’t a panacea for financially stressed healthcare organizations. If not executed and managed carefully, it can create inferior patient outcomes and undermine an organization’s mission. It’s vital that hospitals consider all the risks before adopting a distributed model. By doing so, they can experience the rewards while mitigating potential setbacks.

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Hospitals often outsource important services to companies that prioritize profit over patients

University Distinguished Professor of Marketing, Mays Business School; Senior Fellow, Institute for Healthcare Improvement, Texas A&M University

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Paul Barach, MD, MPH, Maj. (ret.) has received research funding from including: NIH, AHRQ, HRSA, DOD, American Heart Association; Cardiomyopathy Foundation; European Union FP-7/Erasmus Plus; Norwegian Research Council; UK National Institute for Health Research, Department of Health; and Health Quality Improvement Partnership.

Leonard L. Berry does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

Texas A&M University provides funding as a founding partner of The Conversation US.

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Hospitals have long embraced the practice of outsourcing some services to specialized companies. Much of this outsourcing is for nonclinical tasks such as laundry, information technology and cybersecurity, and outsourcing those types of services can boost efficiency and quality.

However, over the past few years there has been a fast-growing trend of hospitals outsourcing clinically relevant services – like anesthesiology and emergency medicine – to companies separate from the hospital. When that happens, hospitals relinquish some of the control they have over quality of care.

One of us is a researcher who studies service quality within health care systems and the other is a practicing physician, researcher and adviser to medical centers who has had direct experience with outsourcing. Together with collaborators, we analyzed published research to better understand the benefits and risks of outsourcing in health care.

Our research focused on four clinically relevant services – emergency care, radiology, laboratory services and environmental services – and we found tangible harm to patients and hospitals when those were outsourced.

Emergency care

When you walk into an emergency room in the U.S., the physician who helps you might not work for the hospital you are in. Two-thirds of U.S. emergency departments use some sort of outsourcing, and more than half of practicing emergency physicians work not for a hospital but for separate companies called contract management groups.

Some of these management groups are owned by private equity firms . The private equity health care model is to purchase private medical practices and consolidate them into a bigger firm that provides outsourced services, quickly increase the firm’s value, and then sell the firm for a handsome profit.

Contract management groups claim to streamline the recruiting and credentialing of emergency department staff to relieve hospitals of these tasks and, hopefully, lower costs. But the elephant in the room for emergency medicine and other medical specialties is that a profit-maximizing goal can conflict with prioritizing the well-being of patients and medical staff.

In emergency care, for example, these contracting groups often have aggressive patient-per-hour quotas and provide incentives for medical staff to order more procedures and tests – even if they’re not warranted. In one study, more than one-third of emergency physicians employed by these groups said they had concerns about losing their job if they raised questions about overtesting, quality of care, or patient treatment – roughly double the rate for doctors employed by hospitals.

Contract management groups have also contributed to surprise billing and excessive collections. For example, in the first six months of 2019, TeamHealth, one of the largest such groups in the U.S. that contracts out emergency room physicians, filed more unpaid-bill lawsuits against patients in Memphis, Tennessee, than three local hospitals did combined. It was only negative publicity that made the company reverse course and stop suing patients.

When you get an MRI or an X-ray, having a radiologist interpret the results is often the most costly and time-consuming part of the process. The potential to speed up interpretation of results and cut costs has led many hospitals to contract with separate, off-site radiology services.

The practice is widespread: About 50% of radiologists say that they have interpreted imaging results away from where the images were taken and a quarter say that off-site interpretation is the majority of their work.

For smaller and rural health care systems that lack the resources to staff in-house radiologists, outsourcing may be essential. But for larger health care systems, outsourcing can sometimes lead to negative clinical and business consequences that outweigh the benefits.

For instance, off-site radiologists often lack access to patients’ prior imaging records or medical history. If these radiologists can’t see how a person’s condition has changed over time, it is harder to make an accurate diagnosis . This can lead to unnecessary and costly further testing. Moreover, off-site radiologists can have a harder time communicating with the physician who ordered the test, potentially reducing the quality and continuity of care .

Finally, there have been numerous reports of for-profit radiology companies using radiology technicians who are not physicians for certain services. Radiology technicians are less expensive to hire than radiologists but also less well trained . A licensed radiologist or physician is required by law to review and sign every report. But in a notorious example, one radiologist who owned a for-profit practice serving 15 U.S. hospitals signed off on more than 71,000 radiology reports during an eight-month period. The company was sued by the U.S. government, with investigators finding that licensed radiologists reviewed fewer than 6,000 – about 8% – of those reports .

Laboratory services

Another commonly outsourced service is bloodwork and other laboratory testing. Quest Diagnostics alone provides some level of lab service to about half of all U.S. hospitals .

While the potential financial savings of using an off-site lab can be alluring to many hospitals, they often face unplanned and sizable cost increases caused by higher test prices, excessive testing and costly management fees. In one study, two academic medical centers that stopped outsourcing laboratory testing and brought it back in-house reported saving $1 million to $4 million in the first year. There is also evidence that outsourcing can result in slower test turnaround times and nonreproducible test results .

Environmental services

Environmental services, previously known as “hospital housekeeping,” are a long underappreciated but key part of infection control in health care – even more so in the COVID-19 era. More than one-third of U.S. hospitals outsource environmental services , but these outside firms often don’t give workers adequate time to clean patients’ rooms, and they tend to pay lower wages than in-house employers do.

In a study of about 300 California hospitals, those that outsourced environmental services reported nearly twice the rate of Clostridioides difficile infections , highly contagious bacterial infections that spread easily in hospitals. Difficult-to-treat staph infections known as MRSA are also more common in hospitals that outsourced their environmental services.

Outsource intelligently

Health care is a unique service that must balance quality of care and people’s very lives with economic realities and profit motives. However, when profit becomes a singularly dominant goal, the best interests of patients, hospital staff and the hospital itself are jeopardized. Profit maximization does not align well with improving the safety and overall quality of patient care.

Many hospitals also are for-profit companies, but unlike contract management groups, hospitals are more visible and financially accountable to the public. Outsourcing has a beneficial role to play in health care when used for the right reasons and with the right partners and guidelines. But when health care systems outsource clinically important services to external companies, there is a real risk that it can lead to patient harm, unhappy staff and higher costs. We believe that outsourcing should be used only when it is the best option for all stakeholders, starting with the patients and staff.

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• Outsourcing
• environmental services
• Emergency medicine
• Patient care
• Healthcare costs
• Lab testing

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Outsourcing in hospitals.

• Mon, 4 Feb 2008

HealthManagement, Volume 10, Issue 1 /2008

A survey of decision-making factors, benefits and obstacles

By Socrates J. Moschuris and Michael N. Kondylis

Outsourcing is an increasingly popular strategy that healthcare organisations can use to control the rising costs of providing services. With outsourcing, an external contractor assumes responsibility for managing one or more of a healthcare organisation’s business, clinical, or hospitality services. Because the contractor specialises in providing a specific service and can achieve economies of scale, he/she may be able to provide a service more efficiently and less expensively than the healthcare organisation.

Outsourcing services peripheral to the organisation’s primary operations may also enable healthcare administrators and staff to concentrate more efficiently on their organisation’s core business.

The aim of this paper is to present, based on the results of a study carried out in 60 hospitals operating in Greece, the decision- making factors, the impact and the obstacles associated with outsourcing in hospitals as well as to provide some managerial implications.

Outsourcing Decision Making Factors

To determine why hospitals decide to outsource activities, respondents were asked to evaluate the importance of a number of factors affecting the decision to outsource.

More than one-half of the respondents indicated that cost savings and customer satisfaction were the most important factors in their decision to outsource, whereas 50 percent of the users mentioned customisation as an important decision-making factor. Focus on core business, lack of personnel, and lack of funds were mentioned as important factors by the minority of the respondents.

Impact and Obstacles of Outsourcing

Regarding organisational impact, respondents were asked to assess the effect of outsourcing on cost reduction, on improvement in customer satisfaction and on the quality of the services provided by the hospitals.

The impact of outsourcing on cost reduction was assessed as high or very high by around two-fifths of the respondents. As far as customer satisfaction is concerned, 60 percent of the respondents indicated a positive or very positive impact.

Finally, around two-thirds of the respondents argued that outsourcing has led to a significant improvement of the services provided by hospitals operating in Greece.

Theoretically, the decision to outsource may lead to an elimination of a number of full-related positions in the healthcare organisation.

Two-thirds of the responding hospitals indicated that their decision to outsource did not lead to an elimination of fulltime related positions, whereas around one-third of the users indicated that they have eliminated between 1 percent and 20 percent of their full-time staff. Only 1 healthcare organisation reported eliminating more than 21 percent of full-time positions due to outsourcing.

According to the survey respondents, healthcare organisations operating in Greece experience a number of benefits from outsourcing .

Improvement in service quality levels was mentioned as the most frequently obtained benefit. Economies of scale, the use of the external provider’s infrastructure, the opportunity for the healthcare organisation to focus on its core business, and enhanced flexibility were also mentioned as important benefits by several other users.

In terms of implementing the decision to outsource, over 70 percent of the users indicated that they experienced significant difficulties/obstacles in bringing contract service providers on-line .

The most often mentioned difficulties included the lack of coordination and integration between the healthcare organisation and the external provider as well as the insufficient understanding of the provider about the user’s operations.

Employees’ resistance to changes as well as price negotiation and billing problems were also mentioned by a number of respondents.

Managerial Implications

The results of this research have important practical implications for those involved in outsourcing investigations in the healthcare sector. The benefits realised after the implementation of the outsourcing decision have explained the relatively high satisfaction level of the users and, hence, the increasing future trend of outsourcing. To those healthcare organisations considering outsourcing of their activities, this positive feedback should be reassuring. The number of experienced organisations provides an important source of information about how to proceed and what to expect.

The most significant reasons for outsourcing are to improve customer service, to reduce costs, to enable healthcare organisations to focus on core activities, and to increase flexibility to configure resources to meet changing market needs.

Some organisations do not achieve the expected benefits from outsourcing, due to lack of formal outsource decision-making process including medium and longterm cost-benefit analyses, resistance to changes, and the inability to formulate and quantify requirements.

The most significant risks of outsourcing lie in the need to develop new management competencies, capabilities and decision-making processes. These include decisions on which activities should remain within the healthcare organisation and which outsourced, whether all or part of the activity should be outsourced, and how to manage relationships rather than internal functions and processes. Mistakes in identifying core and noncore activities can lead healthcare organisations to outsource their competitive advantages. However, what is core one day may not be so the next. Moreover, once organisational competence is lost, it is difficult to rebuild. There is a difficult decision regarding how “close to core” outsourcing should be.

Failure to manage outsourcing relationships properly, perhaps through service level agreements, may reduce customer service, levels of control and contact with customers. The assessment of costs of “make or outsource” should include the additional cost burden of managing the outsource relationships.

Because the introduction of contract services into an organisation represents an important shift in the way in which business is conducted, the provision of appropriate training for employees is an important issue. The training efforts should typically focus on employees’ ability to adjust into another environment and new roles. This includes use of computerised systems, higher skills/knowledge development, and systems support. Once the decision to outsource is accepted, there is little resistance to change by the employees.

The above analysis of the experience of healthcare organisations operating in Greece in their usage of contract service providers indicates that outsourcing in the healthcare sector has a good potential for further development. This study provides contract service providers a framework, which, we hope, will help them in increasing their business in this dynamic and rapidly growing market.

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The outsourcing explosion: Hospitals turn to outside firms to provide more clinical services [Special Report]

Georgia Regents Health System, which operates Georgia Regents Medical Center, Augusta's largest hospital, faced this dilemma. The system, which operates Augusta's only level one trauma center, required improved infrastructure and efficiency in order to keep up with the demands of the region.

So, GRHealth decided to outsource responsibility for much of its imaging services. In 2013, it entered into an agreement with Philips Healthcare to not only provide new imaging equipment, but manage radiology and cardiology services, clinical monitoring of patients, and the relevant education and training for GRHealth staff.

"To some extent, we were looking for was a completely different model for the whole process," James Rawson, M.D., pictured right, who chairs the GRHealth radiology department, said during an exclusive interview with FierceHealthFinance.

The typical arrangement is for the provider to merely lease or purchase the equipment, with the vendor playing a light advisory role.

GRHealth had an ongoing relationship with Philips for years, but after mutual discussion, the two entities decided to take yet another step further.

Although such a deal may appear unique on the surface, it is part of a rising trend of outsourcing of services in the healthcare business and hospital sector. In this special feature, FierceHealthFinance examines the financial benefits of outsourcing and how to avoid potential pitfalls.

Response to financial pressures

Industry observers say hospitals are under pressure to outsource due to lower reimbursements, either through cuts or moves to risk-sharing arrangements as part of the Affordable Care Act, or via actions such as the sequester.

"As hospitals look for ways to reduce costs around activities not core to the hospital's mission...outsourcing is a valid strategy to consider for a financially healthier organization," said The Advisory Board in a recent report about the topic. Another report published in 2013 by Johnson Controls concluded that most providers have to cut expenses by 20 percent by 2020 , and outsourcing is the only way to accomplish this task.

For decades, much of the outsourcing has been in non-clinical operations, such as laundry and operating the cafeteria. But in recent years, outsourcing creeps more closely to clinical operations, with IT, anesthesia services, and in the case of the GRHealth/Phillips relationship, cardiology and radiology services.

Such arrangements allow hospital management to focus more on the big picture of the running the institution while assigning duties to outside firms that have a much more specific focus.

Sheridan, which was founded in the 1950s, operates in 25 states and has more than 2,400 physician affiliates. About 70 percent of its business is with acute care hospitals, with the rest coming from ambulatory surgery centers.

The company not only manages anesthesiology and some other clinical services, but can also improve throughput efficiencies in the operating room and other parts of the hospital, according to Drozdow.

Its proprietary software suite improves communications among physicians on the surgical teams because it helps them avoid canceled medical procedures, which can cost a hospital tens of thousands of dollars of revenue in a single day, creates logistical nightmares in terms of rescheduling and adds to employee overtime.

Offers more OR efficiency

In one case study cited by the Healthcare Financial Management Association , Sheridan was able to reduce the operating room turnover times for a hospital in the Southwest by as much as 35 percent, allowing the organization to add as many as 250 extra patient cases each month.

Sheridan has been a hot property of late. The company was owned for a time by the private equity firm Hellman & Friedman. It sold much of Sheridan to AmSurg last year for $2.35 billion in cash and stock. AmSurg's shares rose nearly 7 percent the day the deal was announced--and another 45 percent since then. Sheridan, which operates as an independent division, has itself acquired or has affiliated with four new anesthesiology and radiology groups since the AmSurg deal closed.

GRHealth has also enjoyed increased efficiencies since the deal with Philips was put into place. System officials said the volume of vascular and interventional radiology scans increased 39 percent; MRIs were up 33 percent; ultrasounds, 29 percent; and CT scans, 11 percent. Although several pieces of existing equipment were upgraded or replaced, the number of scanning devices remained the same. The radiology department was also able to increase these volumes while reducing the number of full-time radiologists by 2.5, or about 10 percent of the total clinical staff.

Prior to working with Phillips, GRHealth management had thought its imaging services had reached full capacity.

"We had been maxed out," said Shawn Vincent, GRHealth vice president of partnerships, pictured right. "With the new technology (Phillips brought in) and the increased throughput, we wound up with volume we would not have had prior."

Avoid potential pitfalls

Despite the potential for increasing efficiencies and saving money, not all outsourcing relationships run smoothly. For example, if clinical and administrative staff are unprepared for the presence of outsourcing executives, resentment can build over their presence, creating unanticipated friction and conflicts.

The Johnson Controls report counsels hospitals and healthcare providers to take these issues under consideration when choosing an outsourcing partner:

Consider appointing a "mentor" from within the organization to oversee the relationship

Insist on continuity in the transition

Set baseline performance and metrics

Expect big cost improvements (there is no other reason to outsource)

Expect more accountability, not less

However, Rawson cautioned that outsourcing pacts are incredibly complicated. He noted that preparations for the actual outsourcing took far longer than anticipated.

"It took a while to get something started," he said. "If others are looking at doing something like this, they should anticipate a whole lot of planning."

Editor's Note: Georgia Regents Health System's name was changed from Georgia Regents to GRHealth on second reference to avoid confusion with the University of Georgia's Board of Regents. Shawn Vincent's name was originally misspelled as Sean.

Outsourcing of Hospital Services: Strategic Capacity Planning Essay

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Outsourcing is an important business process that helps an organization to define the areas that can be used as a competitive advantage (McIvor, 2010). If companies have a chance to use outsourcing with a minimum risk to the staff and the overall situation on the market, they should use it. However, often, the companies are forced to outsource their services to overcome the challenges.

In the case study under consideration, a hospital makes a decision to outsource some services because of the existing financial pressures. In having the outsourced work performed within the hospital (Patnaik, 2015), several advantages could be identified. The majority of all advantages were connected to the possibility to increase the level of satisfaction of the staff. As a rule, workers enjoy the possibility to work under the conditions when they have a feeling of attachment to something.

People got the jobs they liked. They developed the relations that were closed to the family ones. As soon as the workers are satisfied with the working conditions, they are able to produce high-quality work and achieve the results that are expected. There could also be a low level of possible product contamination because a certain group of people should be responsible for all required details. Finally, if people were inspired and organized, the desire to make more necessary improvements could take place with lower financial costs (Chen, Liu, Hua, 2014).

In case a different hospital makes a decision to outsource its food services without having the work performed in-house (Patnaik, 2015), several problems could be identified along with the rationale offered. On the one hand, the employees can lose the required connection between their work, hospital, and satisfaction (Schniederjans, 2006). People may be less inspired by the idea to work properly. On the other hand, the financial position of the hospital may be considerably improved due to the possibility to spend less money on in-house needs and gain control of some other activities that need some improvements.

The peculiar feature of service outsourcing is the presence of positive and negative aspects at the same time. The possibility to reduce costs may result in the necessity to consider the needs of employees. Competitive advantage can influence the quality of services in general and lead to the complaints from the users of hospital services. Finally, the possibility to fill in working places may lead to the creation of a possibility to be weak in regards to the competitors that offer the same services. That is why it is necessary to check each aspect of outsourcing before accepting it and clear up if the workers of the hospitals, who want to believe that their professional relations can be compared to the family ones, are ready for the changes.

In the housekeeping situation discussed in the case study where employee turnover became a problem, it is not reasonable just to forget about outsourcing. Workers should be eager to offer their services to a team. In the case, housekeeping employees suffer from isolation at work and lose that required portion of feelings when they are connected to the hospital they have to work. That is why it is recommended to have only the department director or its manager being outsourced (Ciotti & Pagnota, 2005).

It sounds more effective to consider outsourcing in housekeeping management in order to achieve several benefits. For example, having an outsourced manager means saving money due to the possibility to reduce payroll taxes and gain certain financial benefits. Besides, employees are provided with an opportunity to be more connected to the hospital and develop the required family atmosphere that can reduce the turnover percentage and increase the quality of the services in the nearest future.

Outsourcing is also an ability to pay more attention to various guest services and the marketing sphere. As soon as an outsourced person wears a hotel uniform, any guest has a reason to believe that it is a part of a team and possesses all the necessary characteristics to be in a team (Jones, 2007). Outsourced managers try to demonstrate their best attitudes and focus on the guests’ demands regarding the possibilities of hotel workers. It is a new look at the same challenges that cannot be neglected.

Finally, outsourced managers in the housekeeping department cannot be neglected because this type of managers demonstrates more effective solutions in regards to a variety of unpredictable and volatile situations. The investigations prove that outsourcing is the solution for the volatility that can take place in the hotel industry (Jones, 2007). Sometimes, people cannot understand what move should be taken to succeed.

The workers from the outside are not tied to the traditions of the organization. They make use of the experience and knowledge gained. Outsourced workers in the housekeeping situation want to understand the situation but not people that work in an organization, and that is one of the main reasons why it is better to consider outsourcing even if it leads to employee turnover being a problem.

To find out the rationale for asking another hospital to join the laundry service means to define the benefits that can attract the attention of the whole team. For example, it is possible to pay more attention to the idea of teaming up (for the employees in the laundry department and other departments of the same hotel) and the possibility to become more competitive or even avoid competitions because of the idea of outsourcing.

Taking into consideration the basics of the Porter’s Five Forces Model, the possibility to hire people from another hotel may increase the bargaining power of suppliers and increase the possibility of rivalry among the competitors in the same sphere of business. The way of how management is organized in a company defines the quality of economics and marketing offered by the same organization.

The head of the hotel should be able to define the role of such connection and understand that it is more profitable for the team to be partly outsourced from another hotel to have the options and buy cheaper laundry services, change the cleanliness standards, and make use of the reasonable price that become stable within a short period of time. Sometimes, people cannot notice an evident thing that the possibilities to save money, improve services, and enjoy a variety are the outcomes of the same process. It is just necessary to define the process and take the steps to achieve success. The effectiveness of the laundry services depends on how soon the hotel can choose an organization to outsource several employees and observe the results that can be achieved.

Chen, F., Liu, Y., & Hua, G. (2014). LTLGB 2012: Proceedings of international conference on low-carbon transportation and logistics, and green buildings. New York, NY: Springer Science & Business Media.

Ciotti, V. & Pagnotta, B. (2005). The other side of outsourcing. Healthcare Financial Management Association. Web.

Jones, T.J. A. (2007). Professional management of housekeeping operations. Hoboken, NJ: John Wiley & Sons.

McIvor, R. (2010). Global services outsourcing. New York, NY: Cambridge University Press.

Patnaik, S. (2015). Operations management . Raleigh, NC: Lulu Press.

Schniederjans, A. (2006). Outsourcing management information systems . Hershey, PA: Idea Group Inc.

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• DOI: 10.5455/msm.2013.25.37-39
• Corpus ID: 14344211

Evaluation of Outsourcing in Nursing Services: A Case Study of Kashani Hospital, Isfahan in 2011

• M. Ferdosi , E. Farahabadi , +3 authors P. Naghdi
• Published in Materia socio-medica 1 March 2013
• Business, Medicine

Tables from this paper

19 Citations

Outsourcing in iranian hospitals: findings from a qualitative study, factors influencing decision making for healthcare services outsourcing: a review and delphi study, intensity of nursing work in public hospitals*, exposure of public sector with the quasi-market through outsourcing: a case study in iran, performance evaluation of outsourced medical equipment maintenance service in a tertiary care hospital dr, is it worth outsourcing essential public health services in china-evidence from beilin district of xi'an., exploring perceptions, motivations, and practices regarding outsourcing support services by general hospitals in uganda: a mixed methods study., identifying and prioritizing effective factors on outsourcing in public hospitals using fuzzy bwm, public-private partnership in iranian hospitals: challenges and opportunities, e-commerce and it projects, 19 references, outsourcing in public hospitals: a greek perspective., innovations in health service delivery : the corporatization of public hospitals, health economics in developing countries, qualitative assessment of dimensions and degree of autonomy granting to university hospitals, management concepts, applications & skill development, outsourcing effectiveness of admission units of imaging centers in ayat o allah kashani hospital to non-governmental sector1, outsourcing of medical records services unit: ayat o allah kashani hospital case assossment, related papers.

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Evaluation of outsourcing in nursing services: a case study of kashani hospital, isfahan in 2011

Affiliation.

• 1 School of Management and Medical Education, Isfahan University of Medical Sciences, Isfahan, Iran.
• PMID: 23678338
• PMCID: PMC3633411
• DOI: 10.5455/msm.2013.25.37-39

Background: Hospitals need to focus on their core activities, thus outsourcing of services may be effective in some instances. However, monitoring and supervision is a vital mechanism to preserving and enhancing the quality of outsourced services, and to identify the benefits and losses occurred. The purpose of this study is evaluation of nursing services outsourced in a general hospital from different point of views.

Methods: This is a descriptive and applied study done by case study (before and after) method. Outsourcing nursing services of clinical wards (ENT and Neurosurgery) of Kashani Hospital in 2011 has been studied. We extracted data from a handmade questionnaire about internal customer's satisfaction and semi-structured interviews with officials, and also survey of financial and administrative documents and records related to the topic.

Results: The findings indicate an increased number of graduated nurses per bed to fulfill the main objective of outsourcing in this case. But achieving this objective is accompanied with remarkable increased costs per bed after outsourcing. Besides, we noticed minor changes in internal customer satisfaction rate.

Conclusion: While outsourcing should bring about staff and patients' satisfaction and increase the efficiency and effectiveness, outsourcing nursing workforce singly, leaded to a loss of efficiency. Therefore, the applied outsourcing has not met the productivity for the hospital.

Keywords: Evaluation; Hospital.; Nursing Services; Outsourcing.

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Outsourcing of Hospital Services

“Outsourcing of Hospital Services” 1. In some instances the outsourced service occurs in a different location, while in others it takes place inside the organization doing the outsourcing, ad the food service did in this case.

What advantages were there in having the outsourced work performed within the hospital? Suppose a different hospital outsourced its food service but decided not to have the work performed in- house. What might its rationale be?The advantages in having the outsourced work performed within the hospital were mostly related with the satisfaction of the workers, when the hospital outsourced its cafeteria food services; the employees felt a sense of ownership of their jobs and felt connected to the hospital because of the family atmosphere in the kitchen and cafeteria. When a different hospital outsourced its food service but decided not to have the work performed in-house then they might have to face a problem of employee turnover because the employees might lose the feeling of being connected to the work.Their interest in job will reduce which in future might lead to the problem of employee turnover which won’t be beneficial for the hospital 2. In the housekeeping situation, why not just forget about outsourcing, especially since the hospital ended up rehiring its employees anyways? When the hospital tried the same thing with housekeeping, it didn’t work because employee turnover became a problem.

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After the investigation, they found out the reason for employee turnover which is, because of the housekeeping employees were more isolated in their work, they lost their feeling of being connected to the hospital they had.So, for the benefit of the hospital they ended up rehiring its employees using outsources company to manage housekeeping. These days financial pressures are not the only reason for the outsourcing, hospital executives are finding more reasons to consider outsourcing. The desire to focus on core competencies and the need to fill jobs are also the main reasons for the outsourcing. 3.

For laundry service, what might have been the rationale for asking another hospital to join it?I think the rationale for asking another Rival hospital to join in outsource laundry service, might be because teaming up will be profitable for the hospital because sharing outsource will help hospital to be safe from the competition and could offer a potential vendor more economy of scale. To provide the quality of healthcare service hospital need the specific expert professional and outsources will help to provide the expert professional. Insufficiency in work force will require the outsourcing for hospitals.

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Reimagining healthcare industry service operations in the age of AI

As the healthcare industry continues to evolve, operations leaders face a complex set of challenges, including high administrative costs and employee attrition rates. Administrative accounts for about 25 percent of the more than $4 trillion spent on healthcare annually in the United States. 1 Nikhil R. Sahni, Prakriti Mishra, Brandon Carrus, and David M. Cutler, “ Administrative simplification: How to save a quarter-trillion dollars in US healthcare ,” McKinsey, October 20, 2021. Simultaneously, in response to rising expectations, organizations face continued pressure to improve consumer experiences along the end-to-end healthcare journey.

Against this backdrop, advancements in AI, including generative AI (gen AI), could transform the healthcare industry, boosting operational efficiencies across internal and customer-facing operations at payers, care delivery organizations, and government entities such as the Centers for Medicare & Medicaid Services and public hospitals. In a 2023 survey of operations leaders in the customer care function, 45 percent cited deploying the latest technology, including AI, as a top priority, a 17-percentage-point increase from 2021. 2 “ Where is customer care in 2024? ,” McKinsey, March 12, 2024.

About QuantumBlack, AI by McKinsey

QuantumBlack, McKinsey’s AI arm, helps companies transform using the power of technology, technical expertise, and industry experts. With thousands of practitioners at QuantumBlack (data engineers, data scientists, product managers, designers, and software engineers) and McKinsey (industry and domain experts), we are working to solve the world’s most important AI challenges. QuantumBlack Labs is our center of technology development and client innovation, which has been driving cutting-edge advancements and developments in AI through locations across the globe.

In this article, we explore ways healthcare leaders could use AI to transform their service operations and also outline critical considerations that could help them succeed (see sidebar, “About QuantumBlack, AI by McKinsey”). Service operations encompass financial transactions (such as claims processing); industry-agnostic functions such as finance and human resources; industry-specific functions such as underwriting, enrollment, quality reporting, and accreditation; customer and patient services (the set of activities and processes that provide services to customers); and administrative clinical support functions (such as nursing administration and case management).

Why healthcare leaders struggle to realize digital investments’ full value potential

Digital and AI solutions have substantial potential to optimize operations (for example, through automation) and enhance consumer experiences. Healthcare leaders are committed to investing in AI solutions such as chatbots, conversational AI, and virtual assistants to stay relevant and competitive. 3 “ Where is customer care in 2024? ,” McKinsey, March 12, 2024. However, technology transformation programs across industries, including healthcare, have historically failed to deliver value quickly enough to generate expected ROI; they typically realize less than a third of their expected value. 4 “ Rewired and running ahead: Digital and AI leaders are leaving the rest behind ,” McKinsey, January 12, 2024. Moreover, only about 30 percent of large digital transformation efforts are successful. 5 Tech: Forward , “ Why most digital banking transformations fail—and how to flip the odds ,” blog entry by Akhil Babbar, Raghavan Janardhanan, Remy Paternoster, and Henning Soller, McKinsey, April 11, 2023.

Specifically, operations leaders report difficulty in scaling AI and automation use cases from pilot to production; 25 percent of surveyed leaders indicated this is their biggest challenge. 6 “ Where is customer care in 2024? ,” McKinsey, March 12, 2024. For example, only 10 percent of respondents’ interactions with healthcare organizations’ conversational AI and chatbots fully resolved their queries without a subsequent need to interact with live agents. 7 McKinsey’s 2023 State of Customer Care Survey, n = 340.

Mission-led road map. Leaders often lack a clear view of the potential value linked to business objectives as well as a road map to capture it. Perceptions of value may be overly optimistic, with leaders believing that AI solves all problems or provides a “quick win” compared with yearslong transformation programs. Conversely, leaders may underestimate the transformative potential of AI. Quantitatively and qualitatively measuring value (for example, using metrics for quality, safety, experience, and access) may be lacking, or the organization may not know which domains to prioritize. A detailed analysis of operations could uncover sizable delays in claims approval times, among other claims-related root causes of operational inefficiency, indicating that claims processing could be a high-priority domain for AI transformation.

Talent. Adopting AI requires a distinct set of skills and capabilities. Organizations may lack technical skills and a hiring plan to close gaps, and their upskilling and reskilling programs may lack investment and the right design. At the same time, however, many nontechnical employees in healthcare and other industries are already using gen AI as part of their everyday work and may have a clearer understanding of its value than employers realize. 8 “ The state of AI in early 2024: Gen AI adoption spikes and starts to generate value ,” McKinsey, May 30, 2024.

Leaders can use the adoption of gen AI as the impetus for assessing their overall talent strategies and what work employees consider meaningful and for crafting jobs that boost productivity while also putting people before tech. 9 “ The human side of generative AI: Creating a path to productivity ,” McKinsey Quarterly , March 18, 2024.

Agile delivery. To succeed with AI, organizations may need to accelerate their decision-making and delivery processes, which could entail shifts in funding and overcoming historical cultural norms and attitudes.

Technology and tools. Most healthcare organizations have legacy technology infrastructure, architectures, and tools that are difficult to scale to support AI solutions. For example, based on McKinsey benchmark analysis of healthcare companies, call center tools frequently lack the ability to tag reasons for calls with the level of detail needed to support AI and glean nuanced customer insights, with as much as 60 percent of calls untagged. Workforce management tools often lack advanced forecasting and scheduling capabilities, leading to mismatches between staffing and demand. Enhancing technology infrastructure is vital in addressing these limitations and improving overall efficiency, responsiveness, and service quality.

Data management. Healthcare data needed by AI solutions is heterogenous: unstructured, spread across multiple data sources, and stored in varying data structures. Organizations may lack data maturity—data completeness, data availability, capabilities to mitigate bias and risk, and data governance—needed to support AI solutions. After AI models have been launched, organizations may have difficulty adapting or integrating new data as it becomes available.

Additionally, ensuring compliance with strict privacy regulations—such as the Health Insurance Portability and Accountability Act in the United States and the General Data Protection Regulation in the European Union—is paramount. This effort includes effectively mitigating risks associated with handling sensitive data such as protected health information and personally identifiable information.

Consider a hypothetical health system with plans to implement AI-powered remote patient monitoring to predict and prevent potential health incidents. This use case relies on continuous data collection from various sensors and monitoring devices, such as wearables. The health system is challenged to ensure AI algorithms have access to sufficient data for effective learning and prediction while guaranteeing the anonymity of individual patients.

Changing the operating model. Successful leaders broadly consider AI’s impact on the operating model and on internal and external users. Workstreams dedicated to change management, communication, and training will likely be needed. Integrating AI insights into operations could entail changes to workflow, and leaders will need to ensure the AI algorithm’s outputs are transparent and able to be interpreted.

AI use cases in service operations

Private and public healthcare organizations are increasingly adopting AI to improve patient care and reduce costs (exhibit). Even so, to control risks associated with data privacy and security and ensure quality along with efficiency, most leaders prefer to use AI to augment human decision making rather than replace it entirely.

AI has a number of use cases in service operations across healthcare sectors. (continued)

Best practices for transforming service operations using ai.

Leading organizations are using a set of best practices to transform their service operations with AI.

Prioritize key domains, and clarify their impact across use cases

Prioritizing service domains and defining clear AI use cases is a crucial early step. Some successful organizations have created a heat map to prioritize domains and use cases based on their potential impact (for example, increasing operational efficiency, enhancing customer experience, and supporting business objectives), feasibility to implement, and associated risks. Next, they design AI solutions to pursue high-priority use cases and identify any functional and technical needs and capabilities required to fill gaps. For example, an organization with the contact center as a priority domain could use machine learning algorithms to analyze data and identify drivers of incoming demand, customer sentiment, agent performance, and process breakpoints. Based on this analysis, an organization could identify a use case that would be best served by a customer-facing bot with real-time audio transcription and the ability to route to a human agent for any critical need. The features of the customer-facing bot can be mapped onto specific functional and architectural capabilities to ensure the AI system is designed to meet the specific needs of the use case and can deliver the desired outcomes.

Several AI use cases have proved especially relevant and effective in service operations and delivery. In all cases, minimizing the many risks of AI, including those associated with staff and patient concerns, is paramount to the effort. 10 Shahed Al-Haque, Marie-Renée B-Lajoie, Erez Eizenman, and Nick Milinkovich, “ The potential benefits of AI for healthcare in Canada ,” McKinsey, February 26, 2024; “ Implementing generative AI with speed and safety ,” McKinsey Quarterly , March 13, 2024.

Hyperpersonalized customer touchpoints. About 75 percent of customers across industries now initially engage with an organization digitally and later go on to have an omnichannel experience. 11 McKinsey’s 2023 State of Customer Care Survey, n = 340. This allows leading organizations to provide a hyperpersonalized experience. They are using AI to analyze customer data from multiple sources and generate personalized profiles of customers. This enables customers to engage through their channel of choice and increases the likelihood the organization can resolve a customer’s issues on the spot (without the help of a live agent).

For example, calls about claims and finding care account for about 50 to 70 percent of the total call volume at payer organizations, and a recent surge in billing errors now generates an additional 10 to 15 percent of calls to clarify explanation of benefits, according to McKinsey analysis. Using AI and voice analytics, payers could analyze millions of call recordings in real time, uncover detailed reasons for calls, and devise containment strategies such as more self-service options.

Conversational dialogue for resolving customer issues. Conversational AI bots could be used to resolve or more intelligently route issues of low to medium complexity. Supplementing transactional agent interactions with effective, empathetic virtual assistance AI bots, where appropriate, could enhance the customer experience, the quality of work and outcomes, and employee productivity. Additionally, skills-based analysis using AI tools and smart workflows could help route customers based on their needs to the most capable agent.

Consider the hypothetical case of a member who contacts a payer’s customer service department after being denied claims approval for a nonemergent ambulatory service, such as physical therapy. An AI bot could swiftly analyze claim details, patient history, and policy parameters and offer to send a preauthorization letter to the therapist. This empathetic and efficient virtual assistance enhances the customer experience and boosts employee productivity by managing routine inquiries, freeing human agents to focus on ensuring the quality of output and to devote their attention to more complex tasks.

Agent empowerment. Agent copilots (conversational interfaces that use large language models to support agents in real time) have the potential to help agents better understand customers and suggest responses based on their prior interactions. Gen AI could improve agent knowledge and adherence to processes by enabling them to access knowledge libraries with ease. Successful organizations use cutting-edge AI voice analytics to capture and summarize customer complaints and actions in real time.

In our analysis, about 30 to 40 percent of claims call handling time is dead air as agents search for information. Across industries, less experienced employees use twice as many knowledge resources, our analysis reveals, highlighting personal-coaching opportunities. 12 Shana Lynch, “Will generative AI make you more productive at work? Yes, but only if you’re not already great at your job,” Stanford Institute for Human-Centered Artificial Intelligence, April 24, 2023. AI could be used to generate actionable insights into what helps or hinders the performance of the top- and bottom-quartile employees and offer personalized coaching for frontline agents (via AI-powered nudges) to improve performance. Furthermore, gen AI–powered virtual assistants could help agents handle inquiries more quickly and efficiently. These virtual assistants could help enhance agent responses by analyzing customer sentiment and providing suggestions or targeted prompts based on existing call transcripts and profile data. Virtual assistants could also improve customer sentiment by suggesting techniques to enhance their experience.

AI-enabled automation and planning processes. Healthcare organizations could pursue end-to-end smart-process automation for back-office processes and auditing of customer–agent interactions, as well as AI-enabled workforce management for agile forecasting and scheduling. For example, employees typically spend about 20 to 30 percent of their daily work hours on nonproductive activities such as administrative tasks and idle time, according to McKinsey analysis. AI-driven forecasting and schedule optimization embedded into existing tools could improve employee capacity management. The analysis further showed that by optimizing schedules through AI-enabled shift scheduling, organizations could increase occupancy rates 13 In a call center context, the occupancy rate is the percentage of time agents spend on calls rather than being available to take calls. by 10 to 15 percent, improving overall efficiency, employee productivity, and job satisfaction.

Implement iterative test-and-learn approaches

Implementing AI requires an iterative test-and-learn approach. Using A/B testing for evaluating and refining the performance of different AI models and algorithms, organizations could quickly identify what works and what doesn’t and make necessary adjustments to improve the customer experience. This approach also helps minimize risks and optimize return on AI investments. For example, payers could employ A/B testing to evaluate different configurations of an AI-driven fraud detection model in the context of claims processing. Through systematic testing, they could quickly identify variations in model parameters to determine which algorithm is most adept at detecting fraudulent claims, allowing for timely interventions. This iterative approach not only strengthens the payer’s ability to safeguard against fraudulent activities but also helps streamline claims processing, thereby optimizing operational efficiency and minimizing financial risks.

Set up cross-functional teams

Evolving the operating model and setting up cross-functional teams (business, product, customer service, data and analytics, and IT) is critical for the successful implementation of AI use cases. These teams collaborate to understand and address customer care challenges and opportunities as well as the needs of the business. Cross-functional teams serve as early-adopter champions, shaping deployment of use cases, proving value to build momentum for change, and propelling adoption across the business. For example, in government organizations, a cross-functional team comprising policy makers, healthcare experts, IT specialists, and community representatives could collaborate to implement an AI-driven system for optimizing public health initiatives. This team would work together to address healthcare challenges, enhance patient services, and ensure that the AI solution aligns with the government’s healthcare objectives and citizen needs.

Evolving the operating model and setting up cross-functional teams ... is critical for the successful implementation of AI use cases.

Design customer-backed experiences

Designing a customer-backed experience is essential for the successful implementation of AI in service operations. Leading payer organizations are using feedback and insights from customers to design AI solutions that can meet their needs and preferences. By using natural-language processing (NLP) and sentiment analysis, they could discern customer intent and emotions and provide personalized and contextualized responses. This approach helps improve customer satisfaction, loyalty, and advocacy, and it propels business growth and profitability. For example, a payer organization could use customer feedback and insights to implement AI-driven tools for claims processing. By employing NLP and sentiment analysis, the organization understands the concerns and sentiments expressed by customers in their inquiries. This allows for personalized responses, efficient issue resolution, and an overall improvement in customer satisfaction, contributing to increased loyalty and positive customer sentiment.

How service operations can get started on an AI road map

To initiate an AI-powered service operations transformation, organizations can consider taking the following actions today.

Conduct a rapid diagnostic assessment across operations

Using AI-powered tools such as process insights and speech analytics solutions, organizations could identify process inefficiencies and assess the potential value at stake of improvements (for example, across end-to-end customer care operations, including voice and nonvoice processes). This step can provide deep insights into current-state operations and customer needs and preferences, and it can help identify use cases to address gaps and opportunity areas. For instance, with advancements in AI technologies, depending upon the complexity of the use case, solutions can be implemented in weeks rather than months, allowing organizations to glean insights from day-to-day operations and customer interactions with speed.

Prioritize key domains, and develop initial proofs of concept for use cases

Next, the organization can develop an initial proof of concept for one or two use cases for the prioritized domains—such as gen AI–enabled copilot assistants or speech analytics to support claims queries in the call center—in which the pain is particularly acute and the potential for meaningful improvement is high. Doing so will help leaders understand the potential of these solutions and how they apply to customer care operations.

For example, healthcare payers frequently struggle to process claims with a high degree of complexity. AI-driven claims assistance solutions could help claims examiners make faster and more accurate claim adjudication decisions by suggesting appropriate payment actions and minimizing errors. These solutions could increase processing efficiency for complex claims by more than 30 percent and reduce penalties payers incur for failing to pay claims promptly. 14 Rohit Panikkar, Tamim Saleh, Maxime Szybowski, and Rob Whiteman, “ Operationalizing machine learning in processes ,” McKinsey, September 27, 2021.

Scale additional use cases with an agile, iterative approach

Expanding the effort entails taking an agile, iterative approach to scale additional use cases and build a road map that clearly articulates solutions and priorities tied to specific owners and milestones. To help ensure successful scaling, organizations could form a cross-functional operating model (an AI task force) with representatives from the business, product, customer service, and IT teams and take steps to ensure it enables and supports continuous improvement.

Establish an effective governance framework

As companies move from use case pilots to mainstream adoption of AI and gen AI tools, they will need appropriate governance frameworks and comprehensive risk guidelines to maintain quality and manage risks at scale. These might include ongoing monitoring and auditing mechanisms to assess AI system behavior and ensure that it aligns with established ethical guidelines. Cross-functional teams of AI experts, ethicists, and legal advisers can evaluate AI models and applications for potential biases or ethical concerns. It is essential to identify, codify, and regularly review the ethical, legal, regulatory, and cyber risks of AI implementations. Defining explicit guidelines and policies to manage data, particularly sensitive information such as protected health information and personally identifiable information, can prevent unauthorized access and mishandling of data, including by third parties.

Align talent strategy with the AI and gen AI road map

Successful organizations will align their talent strategy with the use case road map and implementation approach, focusing on critical areas such as member services, claims processing, and policy development. They will set up cross-functional teams to incorporate new technologies and methodologies and ensure seamless integration of competencies, including advanced data analytics for risk assessment, machine learning for claims automation, and precision medicine for personalized policy offerings. To bridge skills gaps, successful organizations will implement targeted training programs and foster a culture of continuous learning and innovation.

The future of AI-enabled service operations for healthcare organizations such as payers, care delivery organizations, and the public sector is promising. Although many operations activities will still require a human touch, AI could help bolster efficiency by streamlining processes and supporting more convenient and personalized services for patients and customers. As the healthcare industry continues to evolve, the use of AI will become increasingly important to reimagining and continuously improving service operations.

Sameer Chowdhary is a partner in the Dallas office, Avani Kaushik is an expert in the Southern California office, and Sagar Soni is a specialist in the Boston office, where Vinay Gupta is a senior expert.

The authors wish to thank Oana Cheta for her contributions to this article.

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• Published: 19 September 2024

Performance analysis of indicators in teaching hospitals after the Health Transformation Plan: a Case Study in Iran

• Bahman Ghasemzadeh 1 ,
• Mohammad Amerzadeh 2 ,
• Saeed Shahsavari   ORCID: orcid.org/0000-0002-0806-6026 3 ,
• Saeideh Moosavi 1 ,
• Abdollah Keshavarz   ORCID: orcid.org/0000-0002-0061-0031 4 ,
• Aisa Maleki 5 &
• Rohollah Kalhor   ORCID: orcid.org/0000-0002-6146-8761 2  

Journal of Health, Population and Nutrition volume  43 , Article number:  151 ( 2024 ) Cite this article

Metrics details

This study aimed to examine the status of performance indicators in hospitals affiliated with Qazvin University of Medical Sciences (QUMS) before and after the implementation of the Health Transformation Plan (HTP).

This longitudinal descriptive-analytical study was conducted utilizing hospital data. The study collected data using a checklist that included both general characteristics of the participating hospitals and performance indicators such as “the number of outpatient visits,” “the number of paraclinical patients,” “the number of surgeries,” and “the number of inpatients” on a monthly basis for 2012–2019. The intervention examined in this study was the implementation of the HTP in May 2014. The data collected was analyzed using interrupted time series and STATA statistical software version 15.

The study examined seven hospitals affiliated with QUMS, including general, trauma, pediatric, gynecology, and psychiatry hospitals. The findings indicated a significant increase in outpatient visits, paraclinical patients, and inpatients in the first month after the intervention. Specifically, there was an increase of 1739 in the number of outpatient visits, an increase of 513 in the number of paraclinical patients, and an increase of 135 in the number of inpatients ( p  < 0.001).

The HTP has improved patients’ access to medical services. It achieved this by reducing out-of-pocket payments for healthcare services and implementing programs such as developing clinics, improving the quality of visits, and retaining doctors in deprived areas. The reduction in out-of-pocket payments has been particularly beneficial for individuals who lack financial resources and previously faced barriers to accessing healthcare services.

Health is a fundamental capital for the development of societies. Healthy individuals are the driving force behind sustainable development [ 1 ]. The main objective of health systems is to enhance the overall health status of the community, protect against the high costs of healthcare services, and address the non-medical needs of the people [ 2 , 3 ]. In recent years, the global approach to health has evolved significantly [ 4 ]. Advancements in knowledge and technology, coupled with an increase in public awareness, have led to a more comprehensive understanding of health and its various dimensions [ 5 ].

The factors influencing health and disease have undergone significant changes in recent times [ 6 ]. As a result, governments have taken major steps to ensure the accessibility of healthcare services by implementing reforms in their health systems [ 7 , 8 ]. These reforms aim to improve the overall performance of health systems by changing various aspects of their functions [ 9 ]. To maintain the effectiveness of health systems, it is crucial to ensure that they are aligned with the global trend, which currently involves changes and reforms in most countries’ health systems worldwide [ 10 , 11 ].

The Ministry of Health and Medical Education (MoHME) is responsible for overseeing the healthcare system in Iran. To achieve the objectives outlined in the vision of 2025 [ 12 ], which includes improving financial protection for the population, promoting equity in access to healthcare services, and enhancing the quality of services, the MoHME has implemented a reform program [ 1 , 13 , 14 ]. The reform program consists of seven programs focused on improving treatment services. These programs include “reducing patients’ payments in hospitals affiliated with the MoHME,” “improving the quality of visit services in hospitals affiliated with the MoHME,” “supporting the retention of physicians in deprived areas,” “enhancing the quality of accommodation services in hospitals affiliated with the MoHME,” “implementing a financial protection program for incurable, special, and needy patients,” “promoting natural childbirth,” and “implementing a specialist house physician program“ [ 1 , 10 , 13 , 15 ].

Hospitals play a crucial role in providing healthcare services and contribute significantly to the government budget. Given their importance, it is essential to evaluate the quality of hospitals’ services [ 16 ]. Hospitals are responsible for providing prevention, early detection, timely treatment, and rehabilitation services to patients [ 17 , 18 ]. The proper functioning of hospitals is critical in ensuring the recovery of patients and their return to society, and any mistakes can lead to significant consequences [ 19 , 20 ].

The hospitals’ performance is crucial for improving the quality of life and has implications for other sectors, including social inequality, rising medical costs, and political problems [ 3 ]. Providing effective and efficient services requires the proper use of resources and improving productivity. Indicators are tools that can be used to monitor the hospitals’ performance, and accurate and continuous reporting of these indicators can improve their efficiency and effectiveness [ 21 , 22 , 23 ].

The World Health Organization (WHO) defines indicators as variables that can directly or indirectly measure change [ 24 ]. Therefore, evaluating changes and developments in the healthcare system requires using a set of indicators, including accessibility, financing, quality, and outcome indicators. Hospital performance indicators are one set of outcome indicators to measure changes in the health system performance indicators, such as the rate of inpatient admissions, outpatient visits, and surgeries are among the most critical indicators that should be regularly examined and evaluated to monitor the hospitals’ performance in different programs and periods [ 25 , 26 , 27 ]. The study aimed to investigate the status of performance indicators in hospitals affiliated with Qazvin University of Medical Sciences (QUMS) before and after the Health Transformation Plan (HTP) and to determine the impact of these reforms on the performance indicators of these hospitals.

Study design

This study was conducted longitudinally based on hospital data and utilized a descriptive-analytical approach. The research was carried out in all hospitals affiliated with QUMS. Data were collected by using a checklist that included general characteristics of hospitals, such as the type of hospital and their features, as well as indicators by month for the years between 2012 and 2019.

The hospitals’ performance was evaluated using four performance indicators approved and prioritized by the MoHME. The indicators used in the study were the number of outpatient visits, the number of paraclinical patients, the number of surgeries, and the number of inpatients. These indicators have been identified as the most important and widely used indicators for measuring the efficiency of hospitals and have been utilized in well-known models such as Pabon Lasso for measuring hospital performance [ 28 , 29 , 30 ].

• Performance indicators

The outpatient visits

It is a healthcare performance indicator that measures the proportion of patients who utilize the treatment and diagnostic services of a hospital’s outpatient department without occupying a hospital bed [ 31 ].

The number of surgeries

It is a healthcare performance indicator that measures the number of surgeries performed in a hospital within a given period and about the number of operating room beds available in the hospital.

The number of inpatients

An inpatient is an individual admitted to a hospital for examination, diagnosis, or treatment requiring at least one overnight stay. The inpatient admission rate refers to the number of admissions to hospital inpatient care per 1,000 people in a defined population, usually within a geographic region [ 31 ].

Data collection

The data was collected from 2012 to 2019. The period consisted of two years before the HTP and five years after. The data was obtained from seven university hospitals in QUMS, Iran, relevant to specific months. BG visited the hospitals to collect the data with the assistance of statisticians, information officers, and informaticians from the respective hospital units. Subsequently, the collected data was verified by matching it separately with available data from the Treatment Vice Chancellor of the University and the Avab Health website of MoHME. Footnote 1 .

Statistical analysis

The study employed an interrupted time series analysis using STATA version 15 statistical software. The data before and after the HTP were considered as time series. The plan’s effect on the level and trend of indicators after implementation was measured.

The interrupted time series model uses two variables to indicate the impact of an intervention: (1) the level variable which determines the immediate effect (2) the trend variable which shows the long-term impact. This means the immediate change in indicator levels at the start of the project (May 2014) and the monthly change thereafter were determined.

The stationarity of the data was checked using the Augmented Dickey-Fuller test to reject the null hypothesis of a unit root for all indicators, indicating stationary time series. The Chow test was used to determine structural breaks in the time series. Finally, serial autocorrelation in the regression residuals was determined to adjust the interrupted regression based on the degree of autocorrelation before estimating the model.

We reviewed seven hospitals, including three general hospitals, one trauma hospital, one pediatric hospital, one gynecology hospital, and one psychiatric hospital. The lowest and highest percentage of bed occupations were related to Amir Al-Momenin (31.2) and Bu Ali Sina (69.64) hospitals, respectively. The background information of the studied hospitals can be seen in Table  1 .

The effect of health system reform on the number of outpatient visits

The interrupted regression results in Table  2 show that before the HTP, the initial number of outpatient visits was 6324, and the monthly changes in outpatient visits were significant for all hospitals ( p  < 0.001). In the first month after the intervention, outpatient visits increased significantly by 1739 ( p  < 0.001). Compared to the pre-intervention trend, outpatient visits increased by 106 per month post-intervention for all hospitals ( p  < 0.001). Figure 1 visually depicts the distribution of outpatient visits from April 2012 to May 2019.

The effect of health system reform on the number of paraclinical patients

The interrupted regression results in Table  2 show that before the HTP, the initial number of paraclinical patients was 2846. The monthly changes in paraclinical patients’ pre-reform were insignificant for all hospitals. In the first month post-intervention, the number of paraclinical patients increased significantly by 513 ( p  < 0.001). Compared to the pre-intervention trend, paraclinical patients increased by 24 per month post-intervention across all hospitals ( p  < 0.001). Figure 1 visually depicts the distribution of paraclinical patients from April 2012 to May 2019.

The effect of health system reform on the number of surgeries

The interrupted regression results in Table  2 show that before the HTP, the initial number of surgeries was 383. The monthly changes in the number of surgeries performed were insignificant for all hospitals. In the first month post-intervention, the change in the number of surgeries was also insignificant. Compared to the pre-intervention trend, the number of surgeries increased by 4.774 per month post-intervention across all hospitals ( p  = 0.001). Figure 1 visually depicts the distribution of the number of surgeries from April 2012 to May 2019.

The effect of health system reform on the number of inpatients

The interrupted regression results in Table  2 show that before the HTP, the initial number of inpatients was 658. The monthly changes in the number of inpatients pre-reform were insignificant for all hospitals. In the first month post-intervention, the number of inpatients increased significantly by 135 ( p  < 0.001). Compared to the pre-intervention trend, the number of inpatients increased by 18 per month post-intervention across all hospitals ( p  < 0.001). Figure 1 visually depicts the distribution of the number of inpatients from April 2012 to May 2019.

Distribution of various performance indicators among the investigated hospitals between April 2012 to May 2019

The study results indicate the HTP had positive impacts and changed most performance indicators in the hospitals before and after implementation. A comparison of the monthly average performance indicators before and after the HTP also showed significant changes. Similar studies have found that health system reforms can increase hospital workflow, evident in this study through higher inpatient volumes and bed turnover [ 31 ]. Several studies, including Sajjadi et al., Yousefzadeh et al., Rezaei et al., Dadgar et al., and Zarei et al., have reported similar findings regarding the impact of health system reform on hospital productivity and bed utilization. These studies have demonstrated that the HTP has had a significantly positive effect on these healthcare performance indicators [ 31 , 32 , 33 , 34 , 35 ].

The implementation of the HTP has had a significant positive impact on the people’s share of hospitalization costs in Iran, as reported by the MoHME. Before the HTP, the people’s share of hospitalization costs was 37%, but this decreased to 4.5% after the implementation of the reform. This has increased people’s access to health services, particularly for low-income groups, and has resulted in increased hospital admissions [ 32 , 36 , 37 ]. It is important to note that while the reduction of payments and the subsequent increase in performance indicators is a positive outcome of health system reform, it should not lead to an increase in induced demand among healthcare providers [ 37 , 38 ].

The findings of Zarei et al.‘s study indicate a significant increase in outpatient visits, with a 26% increase reported [ 33 ]. The reasons for this increase are multifaceted. The development of special clinic programs and the plan to improve the quality of outpatient visits have led to a reduction in the payment of patients in outpatient departments. Additionally, the increase in the number of clinics and staff working hours has improved people’s access to health services. Similar findings have been reported in studies conducted by the WHO in different countries. These studies have shown that the implementation of interventions aimed at removing barriers to the use of health services, such as reducing patients’ payments and increasing accessibility, leads to an increase in the number of outpatient visits.

Rezaei et al. have confirmed the positive impact of the HTP on hospital performance indicators, including the bed occupancy rate, at Hamadan Hospital [ 39 ]. Similarly, Yaser et al.‘s study on the implementation of the health reform plan in the Turkish healthcare system found that it resulted in increased bed occupancy rates [ 40 ]. The employment rate in hospitals studied has also shown an increase of 10% after the implementation of the HTP. This increase can be attributed to several goals of the reform plan, such as reducing the amount of payment for patients, promoting the residency of physicians in deprived areas, and ensuring the presence of specialist doctors in hospitals affiliated with the MoHME. The plan also aimed to improve the quality of visiting and hospital hoteling services and provide financial protection for incurable patients [ 41 ].

The number of paraclinical patients in the current study has increased significantly after the HTP, which is contrary to the results of Farid Far et al.. The reason could be the number of years that have been investigated. In Farid Far et al’s study, only 2013 and 2014 have been considered, but in the present study, 2012 to 2019 are considered [ 42 ].

The present study has found a significant increase in the number of surgeries performed after the HTP. This finding suggests that the treatment of patients who required surgery was carried out promptly by doctors in the hospital. It is possible that the increase in the quality of visiting and hoteling services of the hospital after the HTP contributed to this increase in the number of surgeries. These results are consistent with Rezaei et al. and Dadger et al. who found a positive impact of the HTP on the number of surgeries performed in hospitals [ 39 , 43 ]. Similarly, a study conducted in Turkey reported a significant increase in the number of surgeries after the implementation of the health reform plan [ 44 ].

This study has several limitations. One limitation is the lack of control over other influential and confounding factors that may have impacted the study’s performance indicators. Therefore, the changes observed in the indicators cannot be definitively attributed to the HTP alone. However, it is important to note that no other major interventions were implemented during the HTP that could have influenced the results. Additionally, this study only examined three widely used performance indicators, and other important indicators such as accessibility and justice, quality and effectiveness (such as readmission rate, nosocomial infection rates, staff and patient satisfaction, hospital complaints, and the rate of medical errors) were not analyzed. Future studies should consider analyzing these additional indicators to provide a more comprehensive evaluation of the impact of the HTP on the healthcare system.

The results of this study demonstrate that the HTP had a positive impact on hospital performance indicators. The reform increased access to medical services for patients by reducing out-of-pocket payments and implementing programs, such as developing clinics and improving the quality of visits. The availability of physicians in deprived areas has also improved, which is particularly beneficial for people who have not pursued medical care due to financial constraints. The positive effects of the HTP highlight the importance of implementing policies and programs that promote universal health coverage and access to healthcare services.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. The entire dataset is in Farsi language. The Data can be available in English language for the readers and make available from the corresponding author on reasonable request..

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Acknowledgements

We would like to express our deepest gratitude to all stakeholders, health care providers, and individuals who participated in this study.

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Bahman Ghasemzadeh & Saeideh Moosavi

Non-communicable Diseases Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran

Mohammad Amerzadeh & Rohollah Kalhor

Department of Epidemiology and Biostatistics, School of Health, Alborz University of Medical Sciences, Alborz, Iran

Saeed Shahsavari

Vice Chancellor of Treatment Affairs, Qazvin University of Medical Sciences, Qazvin, Iran

Abdollah Keshavarz

Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran

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BG and RK conceived the study. RK supervised all evaluation phases and revised the manuscript. SS and AK were advisors in methodology and contributed to the intellectual development of the manuscript. MA , AM and SM collected and conducted primary data analysis. All authors read and approved the final version of the manuscript.

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Correspondence to Rohollah Kalhor .

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This article results from a part of the dissertation (ethics code IR.QUMS.REC.1400.267) in the Master’s degree. All protocols were approved by the Ethical Committee of the Qazvin University of Medical Sciences.

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Ghasemzadeh, B., Amerzadeh, M., Shahsavari, S. et al. Performance analysis of indicators in teaching hospitals after the Health Transformation Plan: a Case Study in Iran. J Health Popul Nutr 43 , 151 (2024). https://doi.org/10.1186/s41043-024-00642-z

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Patel V, Chisholm D, Dua T, et al., editors. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2016 Mar 14. doi: 10.1596/978-1-4648-0426-7_ch11

Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4).

Chapter 11 health care platform interventions.

Rahul Shidhaye , Crick Lund , and Dan Chisholm .

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• Introduction

Evidence-based interventions often fail to achieve their goal, not so much because of an inherent flaw in the interventions, but because of the unpredictable behavior of the system around them. Every intervention, from the simplest to the most complex, has an effect on the overall system, and the overall system has an effect on every intervention ( Savigny and Adam 2009 ). As a result of this, the current Disease Control Priorities series has shifted its focus from a strictly disorder-oriented intervention analysis (vertical approach) to a more horizontal approach focusing on health system strengthening.

This chapter seeks to identify cost-effective interventions that can be appropriately packaged for one or more specific mental, neurological, and substance use (MNS) disorders, as well as for different levels or platforms of the health or welfare system. A platform is the level of the health or welfare system at which interventions can be appropriately, effectively, and efficiently delivered. A particular platform is defined on the basis of where the intervention will be delivered (the setting) and who will deliver the intervention (service provider). There are essentially three major platforms for the provision of interventions: population, community, and health care. A specific delivery channel—such as a school—can be the vehicle for the delivery of a particular intervention on a specified platform (the community platform). Similarly, a primary health care center is the delivery channel for a specified platform (the health care platform). Identifying the set of interventions that fall within a particular delivery channel will help decision makers to identify potential opportunities, synergies, and efficiencies. This identification will also reflect how resources are often allocated in practice, for example, to schools or primary health care services, rather than to specific interventions or disorders.

Chapter 10 of this volume ( Petersen and others 2015 ) considers the evidence relating to interventions that improve mental health at the population and community levels. This chapter outlines the main elements and features of a health care platform and its delivery channels, namely, informal health care, primary health care, and specialized services. We consider evidence-based interventions that can be delivered in general health care settings and mental health care settings, as well as broader health system–strengthening strategies for more effective and efficient delivery of services on this platform.

• Elements of a Mental Health Care Delivery Platform

Health care services as a delivery platform for improving population mental health consist of three interlinked service delivery channels:

• Self-care and informal health care
• Primary health care
• Specialist health care.

These three key delivery channels map well onto the commonly cited Service Organization Pyramid for an Optimal Mix of Services for Mental Health supported by the World Health Organization (WHO) ( figure 11.1 ) ( WHO 2003a ). At each subsequent level of the pyramid, the mental health needs of individuals become greater and require more intensive professional assistance, usually resulting in higher costs of care. In certain settings beset with conflict, natural disaster, or other emergencies, a further channel for delivering much-needed mental health care is humanitarian aid and emergency response.

Figure 11.1

World Health Organization Service Organization Pyramid for an Optimal Mix of Services for Mental Health.

Self-Care and Informal Health Care

The foundation of the health care delivery platform rests on self-care and emphasizes health worker–patient partnerships. Persons with MNS disorders and their family and friends play a central role in the management of mental health problems. The role of individuals may range from collaborative decision-making concerning their treatment, to actively adhering to prescribed medication, to changing health-related behaviors, such as drug and alcohol use, stress management, and identification of seizure triggers and avoiding them for seizure control.

Self-care is important for MNS disorders, but it is also important for the prevention and treatment of physical health problems ( WHO 2003a ). Self-care is most effective when it is supported by populationwide health promotion programs and formal health care services. Health promotion interventions delivered at the population level can be important in improving mental health literacy by helping people to recognize problems or illnesses, increasing their knowledge about the causes of disorders and options for treatment, and informing them about where to go to get help (see chapter 10 in this volume, Petersen and others 2015 ).

Informal health care comprises service providers who are not part of the formal health care system, such as traditional healers, village elders, faith-based organizations, peers, user and family associations, and lay people ( WHO 2003a ). Traditional and religious healers are of particular significance, as populations throughout East Asia and Pacific, South Asia, Latin America and the Caribbean, and Sub-Saharan Africa often use traditional medicine to meet their health needs ( WHO 2002 ). In many parts of the world, making contact with such informal providers represents the initial pathway to care ( Bekele and others 2009 ); these service providers are typically very accessible and more acceptable because they are integral members of the local community. Given the widespread presence of traditional and religious healers and the shortage of human resources in mainstream biomedical services, it is imperative that primary health and other formal care services establish strong links with informal health care providers, especially traditional healers ( Patel 2011 ). It is also critical to note that the evidence base regarding the effectiveness of services provided by traditional and religious healers is limited. Nevertheless, it is essential to engage with them, as they provide accessible, acceptable, and affordable care, and efforts need to be made to ensure that their practices do not harm the patients.

Peers are another key human resource at this level of health care. Peer-led education and behavioral interventions have been effective with target populations and health issues in low- and middle-income countries (LMICs) ( Manandhar and others 2004 ; Medley and others 2009 ; Tripathy and others 2010 ). Peers are more numerous, may be perceived as more approachable, and may be able to identify with other community members, as they share similar characteristics, experiences, and health conditions with members of the target population ( Simoni and others 2011 ).

Mental health self-help groups form another key component of informal community care. Mental health self-help groups may be defined as “any mutual support oriented initiative directed by people with [MNS disorders] or their family members” ( Brown and others 2008 , 105). Participation in mental health self-help groups has a positive impact on the clinical and social outcomes of patients with MNS disorders ( Pistrang, Barker, and Humphreys 2008 ). Some of these self-help groups are primarily concerned with the provision of peer support, while others may devote their efforts toward changing public policies and, more broadly, changing public attitudes. Still others may focus on self-empowerment, including monitoring and critiquing the mental health services they are receiving ( Cohen and others 2012 ). Social support also plays an important role in self-management of epilepsy ( Jayalakshmi and others 2014 ; Walker and others 2014 ). However, informal community care should not be viewed as a substitute for publicly funded, evidence-based mental health care.

Stigmatization of and discrimination against people with MNS disorders is common in all sections of society, from community to schools, workplace, and even health care settings. Stigma and discrimination present formidable barriers to social inclusion for affected people and their families, and to access to appropriate health care ( Shidhaye and Kermode 2013 ). This is particularly important in the area of self-care and informal care services, which are relatively less regulated and less subject to quality review or policy oversight. Interventions at the community level to address negative attitudes toward people with MNS disorders and improve health care utilization are covered in chapter 10 in this volume ( Petersen and others 2015 ).

Primary Health Care

Delivery of mental health services through primary health care is a fundamental component of a mental health care delivery platform, since it serves as the first level of care within the formal health care system. The strong emphasis on primary health care is due to the fact that the services provided at this level of the health system are generally accessible, affordable, and acceptable for individuals, families, and communities ( WHO 2003a ). Where the provision of mental health care is integrated into these services, access is improved, MNS disorders are more likely to be identified and treated, and comorbid physical and mental health problems can be managed more seamlessly.

Specialist Health Care

Psychiatric services in first-level hospitals and community mental health services.

People with severe MNS disorders may require hospitalization at some point. First-level hospitals provide an accessible and acceptable location for 24-hour medical care for people with acute worsening of disorders, in the same way that these facilities manage acute exacerbations of physical health conditions ( WHO 2003a ).

The mental health services provided in first-level hospitals also enable 24-hour access to services for any physical health problems that might arise during the course of inpatient stays. Ideally, first-level hospitals will have wards dedicated to the treatment of MNS disorders; these wards will have floor plans that support good observation and care, minimizing the risk of neglect and suicide. To minimize the risk of human rights violations, facilities should adhere to clear policies and guidelines that support the treatment and management of MNS disorders within a framework that promotes human dignity and uses evidence-based clinical practice.

In addition, specialist mental health services are needed in the community for severe cases that cannot be managed by generalists. Examples include assertive community treatment teams and community outreach teams, which provide support to service users to enable them to continue to function in the community without requiring admission, and close liaison with general primary care services and other social and criminal justice services ( WHO 2003a ).

Extended-Stay Facilities and Specialist Psychiatric Services

A small minority of people with MNS disorders requires specialist care ( WHO 2003a ). For example, people with treatment-resistant or complex presentations may need to be referred to specialized centers for further testing and treatment. In LMICs with meager resources, the demand of the population and the emphasis of the public health system is to treat persons with severe MNS disorders. These aspects of care provision along with services for vulnerable populations—such as individuals living in abject poverty; women, especially in childbearing age; children facing abuse; and elderly persons—should not be overlooked when designing programs.

Because of their severe mental disorders or intellectual disabilities and lack of family support, many of these individuals may occasionally require ongoing care in community-based residential facilities. Unfortunately, very scarce resources are allocated to these services. The vulnerable populations require particular attention, from a mental health care perspective and a financial risk protection perspective. The final part of this volume addresses the issue of financial risk protection at length. Forensic psychiatry is another type of specialist service in this category. The need for referral to specialist and extended-stay services is reduced when first-level hospitals are staffed with highly specialized health workers, such as psychiatrists and psychologists.

Emergency Mental Health Care

The traumas, personal losses, and other consequences of armed conflict and disasters place affected populations at an increased risk of mental and behavioral problems; these consequences can overwhelm the local capacity to respond, particularly if the existing infrastructure or health system is already weak. Moreover, the local health care system may have been rendered dysfunctional as a result of the emergency situation, placing further limits on access to key resources, such as mental health professionals or essential psychotropic medicines. There is a heightened need to identify and allocate resources to provide mental health and psychosocial support in these humanitarian settings, for those with mental or behavioral problems induced by emergencies and those with preexisting illness. International humanitarian aid and emergency response at the national level can be a channel for rapidly enabling or supporting the availability of and access to basic or specialist care. In many countries, such emergencies have provided opportunities for systemic change or service reform in public mental health ( WHO 2013a ). Emergency response or relief efforts are essentially concerned with setting up, organizing, and rebuilding services for local populations; the central principles and standard practice of care, including what evidence-based interventions should be prioritized, remain unchanged.

Relationships among Different Delivery Channels

No single service delivery channel can meet all mental health needs. For example, on the one hand, primary mental health care must be complemented by specialist care services that primary health workers can use for referrals, support, and supervision; on the other hand, primary mental health care needs to promote and support self-care and informal community care that encourages the involvement of people in their own recovery. Support of self-care and management can be provided via routine primary care visits or via group sessions led by health or lay workers in health care settings or community venues. Another increasingly accessible option for the effective support of self-care and management is telephone- or Internet-based programs. In short, the potential of the health care system as a delivery platform for enhanced mental health and well-being can only be fully realized if genuine continuity and collaboration of care occur across the three service delivery channels; continuity and collaboration, in turn, rely on an appropriate flow of support, supervision, information-sharing, and education.

• Evidence-Based Interventions for Health Care Delivery Platforms

A strong evidence base supports integrated services across the different delivery channels of the health care platform. This evidence has been synthesized in several publications, including the mhGAP Intervention Guide ( WHO 2010b ); a series of papers on packages of care for MNS disorders in LMICs, published in PLoS Medicine ( Patel and Thornicroft 2009 ); and a report on mental health in primary health care ( WHO and WONCA 2008 ). Earlier disagreement and controversy over emergency mental health care has given way to emerging consensus on key social and mental health intervention strategies and principles, as exemplified by the Inter-Agency Standing Committee’s Guidelines on Mental Health and Psychosocial Support in Emergency Settings ( IASC 2007 ); the inclusion of a mental and social aspects of health standard in the handbook on minimal standards in disaster response ( Sphere 2011 ); and the report on sustainable mental health care after emergencies, Building Back Better ( WHO 2013a ).

For each of the delivery channels, interventions may be categorized as follows:

• Promotion and primary prevention
• Identification and case detection
• Treatment, care, and rehabilitation.

Table 11.1 summarizes the evidence base for interventions by various delivery channels. The interventions are intended as examples rather than as recommendations.

Examples of Evidence-Based Interventions Relating to the Mental Health Care Delivery Platform, by Various Delivery Channels.

• System-Strengthening Strategies for Integrated Health Care Delivery

The availability of evidence-based interventions does not ensure their translation into practice. In this section, we address the question of how to integrate evidence-based mental health care interventions into primary care and self-care delivery channels and how to link this integration to specialist care.

A comprehensive and multifaceted approach that contains the following elements is essential for the successful integration of mental health into health care systems:

• A whole-of-government approach involves the promotion, pursuit, and protection of health through concerted action by many sectors of government. These include ministries of planning and development, finance, law and justice, labor, education, and social welfare. The health system cannot tackle the health, social, and economic determinants and consequences of MNS disorders alone.
• A public health approach stresses the establishment of partnerships between patients and service providers, as well as equitable access for the whole population ( Lund and others 2012 ). This approach requires the integration of care at the patient level. Services should be person centered and coordinated across diseases and settings. Collaborative, coordinated, and continuing care, within a framework of evidence-based interventions, provides the foundation of the public health approach. This means providing good quality, accessible services to those in need, as well as preventing the onset of disease and promoting mental health and well-being over the entire life course ( WHO 2010a ). Priority setting and provision of interventions based on the needs of the population under consideration are also an integral part of the public health approach, which is also central to the work undertaken by the Disease Control Priorities Network.

Table 11.2 summarizes the key features of a public mental health approach.

Key Characteristics of a Public Health Approach to MNS Disorder Prevention and Management.

• A systems approach to integrated service planning and development encompasses the critical ingredients of a health system—good governance, appropriate resourcing, timely information, and the actual delivery of health services or technologies—that need to be in place for desired health outcomes or program goals to be realized. Effective governance, strong leadership, and cogent policy making merit particular mention, since they provide the framework for appropriate action and subsequent service development. Indeed, a well-articulated mental health policy, along with a clear mental health implementation plan and budget, can be a strong driver for change and can appreciably boost efforts to deliver mental health services at the primary care level ( WHO and WONCA 2008 ).

How to operationalize the public health, whole-of-government, and systems approaches to integrate service delivery for MNS disorders is a major challenge. In South Africa, some important steps have been taken toward intersectoral collaboration, particularly at the national level, such as a national forum on forensic psychiatry convened by the Department of Health, with the South African Police Service (SAPS), the Department of Justice, and the Department of Correctional Services. The Departments of Education and Correctional Services have developed policies regarding mental health, and SAPS has developed a standing order that sets out roles and responsibilities for police in relation to mental health. At the provincial level, there are formal collaborations between the government department responsible for mental health and other departments and agencies in most provinces across a range of sectors. Some provinces have also established intersectoral forums for mental health, and intersectoral collaboration is a standing item on the agenda of the quarterly meetings of the provincial mental health coordinators. However, at the district level, such intersectoral collaboration is not common. A policy brief prepared by the Mental Health and Poverty Project provides specific recommendations for shared responsibilities in policy and program development among sectors, such as education, social development, housing, justice and constitutional development, correctional services, labor, local government, public works, and mental health ( MHaPP 2008 ).

Many evidence-based interventions fail to translate into practice because key decision makers, especially in LMICs, are merely seen as targets for dissemination of study results by academicians and researchers. To address this challenge, it is imperative to understand that research should be concerned with the users of the research and not purely the production of knowledge. The users may include managers and teams using research findings, executive decision makers seeking advice for specific decisions, policy makers who need to be informed about particular programs, practitioners who need to be convinced to use interventions that are based on evidence, people who are influenced to change their behavior to have a healthier life, or communities that are conducting the research and taking action through the research to improve their conditions. It is critical to involve these actors in the identification, design, and conduct phases of research and program implementation ( Peters and others 2013 ).

Within the three broad approaches, specific strategies can be identified for integrated health care delivery.

Strategy 1: Improving the Organization and Delivery of Services through Collaborative Stepped Care

Collaborative care is an evidence-based approach to improve the management of MNS disorders at the primary care level. The overall aim of collaborative care is to enhance the quality of care and quality of life, consumer satisfaction, and system efficiency for patients with complex, long-term problems ( Kodner and Spreeuwenberg 2002 ). Collaborative care has been used successfully for the management of common mental disorders, such as depression, as well as for comorbidities cutting across multiple services, providers, and settings ( Katon and others 2010 ). Collaborative care is closely related to a stepped care approach; some programs describe themselves as collaborative stepped care , in that they incorporate aspects of each approach within their interventions ( Patel and others 2010 ). In the stepped care approach, patients typically start treatment with low-intensity, low-cost interventions. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. Programs seek to maximize efficiency by deploying available human resources according to need, reserving the most specialized and intensive resources for those with the most complex or severe problems.

The essential element of collaborative care is a multidisciplinary team approach that seeks to integrate primary care professionals and specialists. Collaborative care rests primarily on the presence of a case manager with enhanced responsibilities for integration of care across comorbid conditions. It starts with systematic identification of those in need, followed by close involvement of patients in joint decision-making regarding their care. It continues with the design of a holistic care plan that includes medication management and psychological interventions and, where appropriate, social care, with a streamlined referral pathway that allows patients to move easily from one service to another. There is provision for regular and planned monitoring of patients and systematic caseload reviews and consultation with mental health specialists regarding patients who do not show clinical improvement ( WHO and Calouste Gulbenkian Foundation 2014 ).

Collaborative care is the best-evaluated model for treating common mental disorders in primary care. A recent Cochrane Collaboration review of 79 randomized controlled trials concluded that collaborative care for depression is consistently more effective than usual care; it has also been shown to be effective in a range of MNS disorders—anxiety disorders and post-traumatic stress disorder—and for improving general health outcomes. The evidence base for collaborative care is mostly from high-income countries (HICs), although evidence from LMICs is growing ( Archer and others 2012 ). It might be very difficult to replicate these case studies directly in low-income settings, but it is possible to extract the lessons from these experiences and contextualize them for a particular setting. There is absolutely no one-size-fits-all strategy for the heterogeneous settings across and within the countries. It is critical to test rigorously and generate evidence around the contextualization of these strategies in low-resource settings. The Balanced Care Model provides guidelines for the inclusion of program components that are appropriate for the available resources ( Thornicroft and Tansella 2013 ).

Mental health programs can be designed on the basis of these guiding principles, drawing on the following case studies.

• The MANAS (MANashanti Sudhar Shodh, or project to promote mental health) study in Goa, India, is the largest mental health care trial to date in that country. The study showed that a lay counselor–led collaborative stepped care intervention for depression and anxiety disorders in primary health care settings led to substantial reductions in the prevalence of these disorders, suicidal behaviors, and days of work lost, compared with usual care. The trial also evaluated the economic impact of the intervention and found that the overall health system costs were lower in the intervention arm, despite the intervention costs, because patients recovered sooner and had lower overall health care costs ( Patel and others 2010 ).
• The Home Care Program for elderly people affected by dementia, led by the Dementia Society of Goa, evaluated a community-based collaborative care model led by lay counselors. The model showed benefits in reducing caregiver burden and improving caregiver mental health ( Dias and others 2008 ).
• In Chile, a multicomponent intervention lasting three months and comprising nine weekly sessions of psychoeducational groups, structured and systematic follow-up, and pharmacotherapy for women with severe depression, and led by nonmedical health workers, demonstrated that at the six-month follow-up, 70 percent of the stepped care group had recovered, compared with 30 percent in the usual-care group ( Araya and others 2003 ). The program is being rolled out across Chile. A similar program was subsequently tested among low-income mothers in postnatal primary care clinics in Santiago, Chile. The program demonstrated significant improvement in the intervention group ( Rojas and others 2007 ).
• In Ibadan, Nigeria, a pilot study evaluated the usefulness of a stepped care intervention for depression. The intervention was delivered by non-physician primary health workers, with support and supervision by physicians and psychiatrists, as needed, using mobile phones. The intervention was based on WHO’s mhGAP guidelines, adapted for the Nigerian health system. Recovery at follow-up, defined as no longer meeting the Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR , 4th edition ( APA 2000 ), major depression criteria at six months, was achieved by 73.0 percent of the participants in the intervention group and 51.6 percent in the usual-care group, representing a risk difference of 21.4 percent. A fully powered study is being implemented to determine the effectiveness and cost-effectiveness of the package ( WHO and Calouste Gulbenkian Foundation 2014 ).
• The Headache Management Trial assessed the effect of a coordinated headache management program in general clinical practice. Patients in the intervention arm received a headache management program consisting of a class specifically designed to inform them about headache types, triggers, and treatment options; diagnosis and treatment by a professional specially trained in headache care; and proactive follow-up by a case manager. This trial demonstrated that a systematic approach to headache care is practical and achievable in a general clinical setting and effectively reduced headache disability in a wide range of patients ( Matchar and others 2008 ).

These case studies primarily focused on evidence generation and were conducted in controlled settings. There are also several case studies from LMICs.

• In the city of Sobral, Brazil, primary care practitioners conducted physical and mental health assessments for all patients as part of integrated primary care for mental health. Primary care practitioners treat patients if they are able, or request an assessment from a specialist mental health team, which makes regular visits to family health centers. Joint consultations are undertaken among mental health specialists, primary care practitioners, and patients. This model ensures good-quality mental health care, and it serves as a training and supervision tool whereby primary care practitioners gain skills that enable greater competence and autonomy in managing mental disorders ( WHO and WONCA 2008 ).
• A similar model is being practiced as part of the District Mental Health Programme in Thiruvananthapuram district, Kerala, India. Trained medical officers diagnose and treat mental disorders as part of their general primary care functions. A multidisciplinary district mental health team provides outreach clinical services, including direct management of complex cases and in-service training and support of the trained medical officers and other workers in the primary care centers. The primary care centers have incrementally assumed responsibility for independently operating mental health clinics with minimal support from the mental health team ( WHO and WONCA 2008 ).
• In the Moorreesburg district of Western Cape province, South Africa, the role of primary care practitioners is filled by general primary care nurses, who provide basic mental health services in the primary health clinic. They are supported by specialist mental health nurses and a psychiatrist, who visits the clinic intermittently to manage complex cases and provide supervision ( WHO and WONCA 2008 ).
• The European Headache Federation and Lifting the Burden: the Global Campaign against Headache ( Steiner and others 2011 ) has proposed a collaborative care model for the management of headache disorders. In this model, 90 percent of people consulting for migraine and tension-type headaches can be diagnosed and managed by staff at the primary care level. In the case of the remaining 10 percent of the patients, common primary and secondary headache disorders can be recognized but not necessarily managed; these can be referred to the next level, where physicians can provide more advanced care. Finally, specialists can provide advanced care to approximately 1 percent of patients first seen at the first-level and second-level facilities, and can focus on the diagnosis and management of the underlying causes of all secondary headache disorders. There is a demonstrational intervention project based on this model in Yekaterinburg, Sverdlovsk Oblast, Russian Federation ( Lebedeva and others 2013 ). Headache services in China have been designed on this model ( Yu and others 2014 ).

The collaborative stepped care approach relies heavily on the introduction of additional human resources, identification of core competencies, adequate training to ensure that these core competencies are fulfilled, and specialist support to maintain these competencies. The next section describes this critical component of mental health system strengthening in more detail.

Strategy 2: Strengthening Human Resources for Mental Health through Task-Sharing

One of the main reasons for the substantial treatment gap for MNS disorders is the lack of a skilled workforce. In HICs, the number of mental health workers is often inadequate; in LMICs, the situation is dramatically worse, with an estimated shortage of 1.18 million workers ( Kakuma and others 2011 ). The collaborative stepped care approach can be implemented only if skilled human resources are available at the different levels of service delivery.

Task-Sharing Approach

Task-sharing is a human resource innovation in which the skills to deliver specific mental health care tasks are transferred to appropriately trained and supervised general health workers. This process helps in improving access to evidence-based mental health care and leads to more efficient use of the limited resources. This approach has been evaluated for mental health service delivery, and its efficacy has been established using rigorous evaluation methodologies ( Araya and others 2003 ; Patel and others 2010 ; Rahman and others 2008 ). Task-sharing is implemented through a collaborative care framework with four key human resources: the community health worker or case manager; the person with a mental health problem and family members; the primary or general health care physician; and the mental health professional ( Bower and Gilbody 2005 ). The overall shortage of human resources can be addressed by introducing newly skilled nonspecialist health workers at the community level; reorienting medical officers and paramedical staff to integrate mental health interventions; and redefining the role of specialists from service providers to leaders, trainers, and supervisors of mental health programs.

The task-sharing approach is at the heart of establishing the collaborative stepped care model of care; the most crucial element in this approach is the availability of a case manager. The results of the MANAS trial clearly indicate the effectiveness of a lay health counselor or case manager leading the collaborative stepped care intervention for common mental disorders in public primary health care facilities in India ( Patel and others 2010 ). Several global case studies have found that primary care for mental health is usually most effective where a mental health coordinator or case manager is responsible for overseeing integration ( WHO and WONCA 2008 ). These case managers can play a crucial role in screening; engaging; educating patients and family members; maintaining close follow-up; tracking adherence and clinical outcomes; and delivering targeted, evidence-based, psychological interventions, such as motivational interviewing, behavioral activation, problem solving, or interpersonal therapy ( Patel and others 2013 ). The case managers can serve as the link between the primary care and self-care platforms, and can work under the close supervision of the medical officers. The evidence base for psychological interventions delivered using a task-sharing approach is set out in box 11.1 .

Clinical and Functional Outcomes of Psychological Interventions Delivered Using a Task-Sharing Approach. Recovery of adults suffering from depression or anxiety, or both, at 7–12 months following the intervention Reduction in symptoms for mothers (more...)

A recent multi-site, qualitative study as part of the PRogramme for Improving Mental health carE (PRIME) investigated the acceptability and feasibility of task-sharing mental health care in five LMICs. The study examined the perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users ( Mendenhall and others 2014 ). Task-sharing mental health services is feasible as long as the following key conditions are met:

• Increased numbers of human resources and better access to medications
• Ongoing structured supportive supervision at the community and primary care levels
• Adequate training and compensation for health workers involved in task-sharing.

Competency-Based Education

Primary care workers function best when their tasks related to mental health service delivery are limited and achievable. The most common reasons for failure to integrate mental health care into primary care programs are the lack of adequate assessment and the overly ambitious target-setting without the necessary customization of the detailed activities, and a full and explicit agreement on the targets and activities needed to achieve them ( Patel and others 2013 ). A shift away from knowledge-based education to competency-based education is needed. This approach mainly focuses on the skills of providers, with the ultimate goal of improving patient outcomes. Competency is defined as an attribute of an individual human resource and the ability of that worker to deliver an intervention to a desired performance standard based on the acquired knowledge and skills.

The Institute of Medicine’s (IOM) Forum on Neuroscience and Nervous System Disorders convened a workshop to discuss and identify core competencies that specialized and nonspecialized primary care providers might need to help ensure the effective delivery of services for depression, psychosis, epilepsy, and alcohol use disorders in Sub-Saharan Africa ( IOM 2013 ). Table 11.3 lists the steps to strengthen human resource competencies for MNS disorders; the core competencies for all service providers across MNS disorders are listed in table 11.4 . In addition to the common competencies for all service providers, the IOM framework also focuses on a diverse range of cadre-specific competencies.

Steps to Strengthen Human Resource Competencies for MNS Disorders.

Core Competencies for All Service Providers across MNS Disorders.

Pre-service and in-service training of primary care workers on mental health issues is an essential prerequisite for the integration of mental health into primary care platforms. The training, to the extent possible, should happen in primary care or community mental health care facilities, to ensure that practical experience is gained and that ongoing training and support are facilitated ( WHO and WONCA 2008 ). The effects of training are nearly always short lived if health workers do not practice newly learned skills and receive ongoing specialist supervision. A trial from Kenya did not find any impact of the training program of medical officers on improvement in diagnostic rates of mental disorders ( Jenkins and others 2013 ). A quasi-experimental study from Brazil had similar findings and noted that wider changes in the system of care may be required to augment training and encourage reliable changes in clinical practice ( Goncalves and others 2013 ). Ongoing support and supervision from mental health specialists are essential. Case studies from Australia, Brazil, and South Africa have demonstrated that a collaborative stepped care approach, in which joint consultations and interventions occur between primary care workers and mental health specialists, increases the skills of primary care workers and builds mental health networks ( WHO and WONCA 2008 ).

Specialist Transitioning

Specialists, especially in LMICs, are usually engaged in service delivery. It is imperative to make a transition from providing clinical services to training and supervising the primary health care staff and providing direct clinical interventions judiciously and sparingly. In separate projects focusing on integrated primary care for mental health in the city of Sobral, Brazil, and the Sembabule district of Uganda, specialists together with medical officers in primary care visited primary care settings and assessed patients. Over time, psychiatrists started taking less active roles, while general practitioners assumed added responsibilities, under the supervision of the psychiatrists. Specialists can interact with primary care staff via referral and back-referral ( WHO and WONCA 2008 ).

Planning and Consultation

Involving primary health care staff in the overall program planning and rollout process enhances ownership and commitment to achieve the planned outcomes within agreed timelines ( Patel and others 2013 ). Consultations with general practitioners have been demonstrated to be one of the key factors in the success of the new mental health services in Australia ( WHO and WONCA 2008 ). Decisions need to be made after careful consideration of local circumstances; this requires consultation with policy makers as well as users of mental health services and their families and the primary care staff.

Psychotropic Medications

It is important to ensure that primary care staff members have the appropriate permission to prescribe psychotropic medications, and they must be adequately trained to perform this task. In many countries, nurses and even general physicians are not permitted to prescribe psychotropic medications. If access to psychotropic medications is to be improved, then initiatives to allow primary care nurses to prescribe psychotropic medications need to be promoted and undertaken, provided appropriate training and supervision is conducted. In Belize, psychiatric nurse practitioners have been given additional prescription rights. In Uganda, general primary care nurses are permitted to prescribe psychotropic medication to patients who require continued medication on the recommendation of a mental health professional ( WHO and WONCA 2008 ).

Strategy 3: Integrating Mental Health into Existing Health Programs

MNS disorders frequently occur throughout the course of many noncommunicable diseases and infectious diseases, such as HIV/AIDS and tuberculosis, increasing morbidity and mortality ( Prince and others 2007 ). People with comorbid disorders risk poor outcomes for both disorders. To achieve the desired outcomes for priority programs in the health sector, it is crucial to manage MNS disorders, pursue synergies in the health system, and deliver interventions through integrated approaches to care. Expansion and integration of mental health services in primary health care can be achieved by using existing service delivery for maternal and child health, noncommunicable diseases, and HIV/AIDS and tuberculosis ( Collins and others 2013 ). Patients with severe MNS disorders often do not receive appropriate care for their general health conditions because of the negative attitudes of service providers, resulting in reductions of 10–25 years in life expectancy compared with the general population. Integration of MNS services within other health care platforms is essential.

Maternal and Child Health Programs

Maternal depression is the second leading cause of disease burden in women worldwide, following infections and parasitic diseases ( Rahman and others 2013 ). Systematic reviews from HICs provide evidence of the effectiveness of psychological therapies—including cognitive behavioral therapy (CBT) and interpersonal therapy that can be delivered in individual or group format—and pharmacotherapy in the treatment of maternal depression ( Rahman and others 2013 ). Promising evidence suggests the benefits of the integration of maternal mental health into maternal and child health (MCH) programs. Examples of community-based trials with a maternal mental health component integrated into an MCH program, and a case study demonstrating that the screening and management of maternal mental disorders can be integrated successfully into an existing health system at a facility level, build a strong case for the integration of mental health care into MCH programs ( Rahman and others 2013 ). The Thinking Healthy Programme in Pakistan is a simple and culturally appropriate intervention for integrating depression care into an MCH program. The intervention is child centered, ensuring buy-in from the families and avoiding stigmatization. It is woven into the routine work of the community health workers, so it is not perceived as an additional burden. The Thinking Healthy Programme has been further adapted so that it can be used universally for all women rather than only depressed women ( Rahman and others 2013 ).

The Perinatal Mental Health Project in the Western Cape Province in South Africa developed a stepped care intervention for maternal mental health that is integrated into antenatal care in three primary care midwife obstetric units ( Honikman and others 2012 ). Midwives are trained to screen women routinely during their antenatal visits for maternal mood and anxiety disorders. Women who screen positive for anxiety or depression are referred to onsite counselors who also act as case managers. Women are referred to an onsite psychiatrist when specialist intervention is indicated. The Perinatal Mental Health Project works directly with facility managers and health workers through collaborative partnerships, focusing on problem solving and capacity development in the primary health care system. Over a three-year period, 90 percent of all women attending antenatal care in the maternity clinic were offered mental health screening, with 95 percent uptake. Of those screened, 32 percent qualified for referral; of these, 47 percent received counseling through the program. This case study clearly demonstrates that onsite, integrated mental health services can increase access for women who have scarce resources and competing health, family, and economic priorities ( Honikman and others 2012 ).

Parenting skills training aims to enhance and support the parental role through education and skills enhancement, thereby improving emotional and behavioral outcomes for children. Primary health care workers can play a significant role in this training. The use of scarce professional resources to train parents is a cost-effective use of resources. Several systematic reviews have shown parent skills training to be effective for reducing internalizing and externalizing problems in children ( Furlong and others 2012 ; Kaminski and others 2008 ), as well as reducing the risk of unintentional childhood injuries ( Kendrick and others 2013 ) and improving the mental health of parents ( Barlow and others 2014 ). Individual and group parent training have been beneficial. Four components of parenting skills training have been found to be most effective:

• Increasing positive parent-child interactions
• Teaching parents how to communicate emotionally with their children
• Teaching parents the use of time-out as a means of discipline
• Supporting parents to respond in a consistent manner to their children’s behavior ( Kaminski and others 2008 ).

Noncommunicable Disease Programs

Existing service delivery platforms for noncommunicable diseases are also promising entry points for the integration of mental health into primary care. The collaborative care models discussed demonstrate a strong evidence base for integration in primary care settings.

In North America, TEAMcare USA and TEAMcare Canada provide team-based primary care for diabetes, coronary heart disease, and depression. TEAMcare trains primary care staff to work in collaborative teams that deliver care in a clinic and by phone. Each service user is assigned a TEAMcare care manager, usually a medically supervised nurse, who serves as the conduit for the consultation team, the primary care team, and the service user. The program takes a treat-to-target approach, modifying treatment as needed to ensure improvement in symptoms. The program teaches self-care skills to service users to control illnesses and encourages behaviors that enhance the quality of life. About 1,400 people have received TEAMcare, with a trial showing improvements in medical disease control and depression symptoms ( Katon and others 2012 ). In the United Kingdom, 3 Dimensions of Care for Diabetes uses a team consisting of a psychiatrist and a social worker from a nongovernmental organization embedded in the diabetes care team to integrate medical, psychological, and social care for people with diabetes and mental health problems, and social problems, such as housing and debt ( Parsonage, Fossey, and Tutty 2012 ).

The National Depression Detection and Treatment Program in Chile integrated depression care with more traditional primary care programs for the management of hypertension and diabetes within a network of 520 primary care clinics. The program follows a collaborative stepped care approach and is led by psychologists, with additional support from physicians and specialists for severe depression ( Araya and others 2012 ). In Myanmar and several other LMICs, epilepsy has been included as part of the process of local adaptation and implementation of WHO’s package of essential noncommunicable disease interventions in primary care ( WHO and Calouste Gulbenkian Foundation 2014 ).

Care for patients with dementia can be well integrated with health care for noncommunicable diseases. Patients with dementia need to be assessed for behavioral and psychosocial symptoms, in addition to a careful physical assessment to monitor hearing and visual impairments, pain, constipation, urinary tract infections, and bed sores that may explain some exacerbation of psychological symptoms. Monitoring and effective treatment of vascular risk factors and diseases, including high blood pressure, hypercholesterolemia, smoking, obesity, and diabetes, to improve secondary prevention of cerebrovascular events, are an integral component of care. A well-conducted clinical trial of cognitive stimulation (reality orientation, games, and discussions based on information processing rather than knowledge) conducted in the United Kingdom as a group intervention and a small pilot trial from Brazil suggest that cognitive benefits from this intervention are similar to the benefits from pharmacological management of dementia using cholinesterase inhibitors ( Prince and others 2009 ). Cognitive rehabilitation, an individualized therapy designed to enhance residual cognitive skills and cope with deficits, showed promise in uncontrolled case series undertaken in HICs. A large body of literature attests to the benefits of caregiver interventions in dementia. These include psychoeducational interventions, often caregiver training; psychological therapies such as CBT and counseling; caregiver support; and respite care ( Chapter 5 in this volume, Thakur and others 2015 ). Many interventions combine several of these elements. Interventions targeting the caregiver may have small, but significant, beneficial effects on the behavior of the person with dementia.

HIV/AIDS and Tuberculosis Programs

WHO’s Integrated Management of Adult and Adolescent Illness (IMAI) is a broadly disseminated health care strategy that addresses the overall health of patients with HIV/AIDS and co-occurring tuberculosis; clear opportunities exist for the integration of mental health in this program. IMAI promotes the inclusion of mental health in the overall care model for HIV/AIDS, as the mental health needs of many persons living with HIV/AIDS can be largely addressed with little duplication or waste, while improving program outcomes, such as antiretroviral drug adherence ( WHO 2013b ). Interventions for substance use disorders can be integrated with HIV/AIDS interventions. This delivery channel can be used to identify individuals who use injectable drugs, as well as those with dependence on opioids, cannabis, and cocaine. The evidence base supports the efficacy of brief interventions on harm from drug use and the overall pattern of drug consumption, including drug abstinence. The brief intervention constitutes a single session of 5–30 minutes, incorporating individualized feedback and advice on reducing or stopping cannabis/psychostimulant consumption, and the offer of follow-up ( NICE 2008 ).

In South Africa, the government has published integrated guidelines for all primary health workers, including HIV/AIDS; major noncommunicable diseases; and a range of mental health problems, including depression, anxiety, mania, substance abuse, and psychosis. These guidelines, called Primary Care 101 (PC101) ( DOH 2012 ), are used by the national Department of Health as part of a primary care revitalization program to deliver integrated care within a chronic disease management framework ( Asmall and Mahomed 2013 ). This approach includes consolidating care for all patients with chronic diseases into a single care delivery point at the facility level and strengthening clinical decision support for nurses. PC101 provides a set of clinical algorithms using a pragmatic signs-and-symptoms approach and integrates detection and management of MNS disorders with other chronic conditions. The guidelines include training materials delivered in a cascaded train-the-trainer format and ongoing support for primary care practitioners from trainers at the district and sub-district levels. At the community level, outreach teams of community health workers are trained to support clinically stable patients and self-care.

• Quality of Care for MNS Disorders

Quality in health care has been defined by the IOM as the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge ( IOM 2001 ). Good-quality care is effective, efficient, equitable, timely, person centered, and safe, and delivers a positive patient experience ( IOM 2001 ).

Despite the strong and growing knowledge base for delivery of mental health services, the treatment gap for MNS disorders remains unacceptably large, with over 90 percent of people with mental disorders in LMICs going without treatment ( Kohn and others 2004 ). This treatment gap is not just a quantitative phenomenon; it also contains an important quality of care dimension. There is a significant gap between what is known about effective treatment and what is actually provided to and experienced by consumers in routine care ( Proctor and others 2009 ). In the language of universal health coverage, it is the difference between contact coverage and effective coverage; that is, substantial improvement in access to care needs to be accompanied by improvement in the quality of service delivery. The inadequacy of resources and low priority given to MNS disorders might suggest that consideration of the quality of care is subservient to the quantity of available and accessible services. However, quality improvement (QI) mechanisms ensure that available resources are well-utilized, in the sense that those in contact with services actually derive appropriate benefit from evidence-based interventions.

Moreover, good-quality services help to build people’s confidence in making use of mental health care interventions, increasing the likelihood of seeking the care that they need ( Funk and others 2009 ). Low-quality services lead people with MNS disorders to experience human rights violations and discrimination in health care settings. In many countries, the quality of care in inpatient and outpatient facilities is poor or even harmful and can actively hinder recovery ( The Health Foundation 2013 ).

QI methods have been shown to be effective for sustained scale-up and adaptation of standardized treatment packages for Millennium Development Goal health priority areas. QI could be included as a routine part of mental health implementation and customization ( Patel and others 2013 ). Quality assurance (QA) involves the use of tools and logic to assess quality performance. QI is the use of methods to enhance quality performance. QA/QI is an integrative process for identifying current levels of quality and improving the quality of performance. QA/QI plays an important role in monitoring and improving the implementation of evidence-based practices; it also helps to monitor and improve the quality of training and supervision required for the delivery of services. Some important QI approaches are continuous quality improvement, Lean, Six Sigma, Plan Do Study Act, Statistical Process Control, and Total Quality Management ( The Health Foundation 2013 ).

QI frameworks and guidelines for LMICs have been developed in the form of a WHO guidance package for QI in mental health services ( WHO 2003b ). The package provides an integrated resource for the planning and refining of mental health systems on a national scale ( Funk and others 2009 ). In a quality framework, standards and criteria are important tools for assessment and improvement. A standard is a broad statement of the desired and achievable level of performance against which actual performance can be measured. The criteria are measurable elements of service provision. Criteria relate to the desired outcome or performance of staff or services. The standard is achieved when all criteria associated with it are met.

Protection of human rights is a critical aspect of the quality of mental health care. The treatment provided in health care settings is often intended to keep people and their conditions under control rather than to enhance their autonomy and improve their quality of life. People can be seen as objects of treatment rather than human beings with the same rights and entitlements as everybody else. They often are not consulted on their care or recovery plans; many receive treatment against their wishes. The situation in inpatient facilities is often far worse: people may be locked away for weeks, months, and even years in psychiatric hospitals or social care homes, where they can be subject to dehumanizing, degrading treatment, including violence and abuse ( WHO 2003b ).

WHO developed the QualityRights Toolkit to assess and improve the quality of life and human rights of people with MNS disorders receiving treatment in mental health and social care facilities ( WHO 2012 ). People living in these facilities are isolated from society and have little or no opportunity to lead normal, fulfilling lives in the community. WHO recommends that countries progressively close down this type of facility and instead establish community-based services and integrate mental health into primary care services and the services offered by general hospitals. Although this tool does not endorse long-stay facilities as an appropriate setting for treatment and care, as long as these types of facilities continue to exist all over the world, there is a need to promote the rights of those residing in them.

The QualityRights Toolkit covers the following five themes drawn from the United Nations Convention on the Rights of Persons with Disabilities:

• Right to an adequate standard of living and social protection
• Right to enjoyment of the highest attainable standard of physical and mental health
• Right to exercise legal capacity and the right to personal liberty and security of person
• Freedom from torture or cruel, inhuman, or degrading treatment or punishment and from exploitation, violence, and abuse
• Right to live independently and be included in the community.

A comprehensive assessment of facilities based on these themes can help to identify problems in existing health care practices and to plan effective means to ensure that the services are of good quality, respectful of human rights, and responsive to the users’ requirements, and promote the users’ autonomy, dignity, and right to self-determination.

• Conclusions

This chapter has described the health care delivery platform and its delivery channels and evidence-based interventions. The key points for effective and efficient delivery of mental health services are as follows:

• To deliver interventions for MNS disorders, the focus needs to move from vertical programs to horizontal health service platforms.
• The WHO pyramid framework of self-care, primary care, and specialist care continues to provide a useful approach for understanding potential delivery channels.
• A set of evidence-based interventions within this framework can be identified for promotion and prevention; identification and case detection; and treatment, care, and rehabilitation interventions.
• The delivery of these interventions requires an approach that embraces public health, systems, and whole-government principles.
• The key strategies for this delivery are implementing collaborative stepped care, strengthening human resources, and integrating mental health into general health care.
• Finally, it is important not only to improve access to health services, but also to focus on improving the quality of care delivered.

Recommendations for policy makers include adopting these principles and strategies using a platformwide approach. Policy makers need to engage with a wide range of stakeholders in this process and make use of the best available evidence in a transparent manner.

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Disclaimer: Dan Chisholm is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication, and they do not necessarily represent the decisions, policy, or views of the World Health Organization.

This chapter was previously published as an article by R. Shidhaye, C. Lund, and D. Chisholm, titled “Closing the Treatment Gap for Mental, Neurological, and Substance Use Disorders by Strengthening Existing Health Care Platforms: Strategies for Delivery and Integration of Evidence-Based Interventions.” International Journal of Mental Health Systems , 2015: 9 (40). doi:10.1186/s13033-015-0031-9.

• Low-income countries (LICs) = US$1,045 or less
• Middle-income countries (MICs) are subdivided: a) Lower-middle-income = US$1,046 to US$4,125 b) Upper-middle-income (UMICs) = US$4,126 to US$12,745
• High-income countries (HICs) = US$12,746 or more.

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Attribution —Please cite the work as follows: Patel, V., D. Chisholm., T. Dua, R. Laxminarayan, and M. E. Medina-Mora, editors. 2015. Mental, Neurological, and Substance Use Disorders . Disease Control Priorities, third edition, volume 4. Washington, DC: World Bank. doi:10.1596/978-1-4648-0426-7. License: Creative Commons Attribution CC BY 3.0 IGO

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• Cite this Page Shidhaye R, Lund C, Chisholm D. Health Care Platform Interventions. In: Patel V, Chisholm D, Dua T, et al., editors. Mental, Neurological, and Substance Use Disorders: Disease Control Priorities, Third Edition (Volume 4). Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2016 Mar 14. Chapter 11. doi: 10.1596/978-1-4648-0426-7_ch11
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Yekaterinburg

Yekaterinburg [lower-alpha 1] is a city and the administrative centre of Sverdlovsk Oblast and the Ural Federal District , Russia. The city is located on the Iset River between the Volga-Ural region and Siberia , with a population of roughly 1.5   million residents, [14] up to 2.2   million residents in the urban agglomeration. Yekaterinburg is the fourth-largest city in Russia, the largest city in the Ural Federal District, and one of Russia's main cultural and industrial centres. Yekaterinburg has been dubbed the "Third capital of Russia", as it is ranked third by the size of its economy, culture, transportation and tourism. [15] [16] [17] [18]

Imperial era

Contemporary era, demographics, administrative districts, administration, living costs and the labor market, finance and business, retail and services, transportation, public transit, media and telecommunications, life and culture, architecture, international relations, bric summit, twin towns – sister cities, notable people, bibliography, external links.

Yekaterinburg was founded on 18 November 1723 and named after the Orthodox name of Catherine I (born Marta Helena Skowrońska), the wife of Russian Emperor Peter the Great . The city served as the mining capital of the Russian Empire as well as a strategic connection between Europe and Asia. In 1781, Catherine the Great gave Yekaterinburg the status of a district town of Perm Province , and built the historical Siberian Route through the city. [3] Yekaterinburg became a key city to Siberia, which had rich resources. In the late 19th century, Yekaterinburg became one of the centres of revolutionary movements in the Urals. In 1924, after the Russian SFSR founded the Soviet Union , the city was renamed Sverdlovsk after the Bolshevik leader Yakov Sverdlov . During the Soviet era, Sverdlovsk was turned into an industrial and administrative powerhouse. On 23 September 1991 the city returned to its historical name.

Yekaterinburg is one of Russia's most important economic centres and was one of the host cities of the 2018 FIFA World Cup . The city is currently experiencing an economic and population boom, which resulted in some of the tallest skyscrapers of Russia being located in the city. Yekaterinburg is home to the headquarters of the Central Military District of the Russian Armed Forces , as well as the presidium of the Ural Branch of the Russian Academy of Sciences .

Yekaterinburg is famous for its constructivist architecture [19] [20] [21] and is also considered the "Russian capital of street art ". [22] [23] [24]

The area was settled in prehistory. The earliest settlements date to 8000–7000   BC, in the Mesolithic period . The Isetskoe Pravoberezhnoye I archaeological site contains a Neolithic settlement dated to 6000–5000   BC. It includes stone processing workshops with artefacts such as grinding plates, anvils, clumps of rock, tools, and finished products. Over 50 different types of rock and minerals were used in tool making, indicating extensive knowledge of the region's natural resources. The Gamayun peninsula (left bank of the Verkh-Isetsky Pond) has archaeological findings from the Chalcolithic Period : workshops for producing stone tools (upper area) and two dwellings of the Ayat culture (lower area). There are also traces of the Koptyak culture from 2000   BC: dishes decorated with bird images and evidence of metallurgical production. The Tent I site contains the only Koptyak culture burials discovered in the Ural Mountains . In the Bronze Age , the people of Gamayun culture lived in the area. They left fragments of ceramics, weapons, and ornaments. [25] [26] [27]

Archaeological artifacts in the vicinity of Yekaterinburg were first discovered during railway construction, at the end of the 19th century. Excavation and research began in the 20th century. Artifacts are held at the Sverdlovsk Regional Museum of Local Lore , at the Hermitage , at the Museum of Anthropology and Ethnography of the Academy of Sciences, and at other museums. [26]

The first Russian settlements within the boundaries of modern Yekaterinburg appeared in the second half of the 17th century — in 1672, an Old Believers village arose in the area of Shartash lake [28] (this fact is disputed by historians, since no evidence of the founding of the village at that time was found in the sources), [29] and in 1680 – 1682, the villages of Nizhny and Verkhny Uktus appeared on the banks of Uktus River (now the territory of the Chkalovsky district of the city). [30] In 1702, by the initiative of the head of Sibirskiy prikaz Andrew Vinius , the Uktus state ironwork plant was founded near Nizhny Uktus — the first ironworks within the boundaries of modern Yekaterinburg. [31] In 1704, the Shuvakish ironworks was built (now the territory of the Zheleznodorozhny district of the city). [28] With the beginning of active construction of factories in the Urals in the 18th century, relations with their southern neighbors, the Bashkirs , became strained. As a result of the Bashkir raid in 1709, the village of Verkhny Uktus was devastated, all buildings, including the wooden church and chapel, were burned, the residents fled to the protection of the Uktus plant fortifications. [30] On the night of 5 April 1718, a fire destroyed all the factory buildings of the Uktus plant, except for the dam, and the plant was restored only by 1720 under the supervision of Timofey Burtsev. [32] However, the plant did not receive further development due to the lack of water in Uktus river.

In 1720, by decree of Peter I , a delegation led by mining specialist Johann Blüher and statesman Vasily Tatishchev was sent to the Urals . [33] They were entrusted with managing the mining industry, identifying the causes of the collapse and reduction of production at state-owned factories. [33] On 29 December 1720, [33] Tatishchev and Blüher arrive at the Uktus plant, which became their main residence in the Urals. As a result of familiarizing himself with the state of nearby state-owned factories, Tatishchev came to the conclusion that on the basis of these factories, even if they were reconstructed and expanded, it would not be possible to quickly increase the production of iron, and it would be more profitable to build a new large plant. After inspecting the immediate area, together with the commissary of the Uktus plant, Timofey Burtsev, a place rich in ore and forest was chosen on the banks of the more full-flowing Iset River , 7 versts from Uktus. [33] On 6 February 1721, Tatishchev sent a message to the Collegium of Mining , in which he asked permission to begin construction of the plant, with detailed explanations and justification for this project. [33] On 1 March 1721, without waiting for a response from the Collegium, Tatishchev began construction of the new plant, [28] but he failed to convince Collegium, and by the Collegium decree of 10 December 1721, he was removed from the leadership of mining affairs in the Urals. [28] In 1722, by decree of Peter the Great, a mining engineer, Major General Georg Wilhelm de Gennin , was sent to the Urals in place of Tatishchev. Having studied all the circumstances, de Gennin fully supported Tatishchev’s project, and on 12 March 1723, construction of the plant on Iset resumed. [28]

Russian historian Vasily Tatishchev and Russian engineer Georg Wilhelm de Gennin founded Yekaterinburg with the construction of a massive iron-making plant under the decree of Russian emperor Peter the Great in 1723. [34] They named the city after the emperor's wife, Yekaterina, who later became empress regnant Catherine   I . [2] Officially, the city's founding date is 18 November 1723, when the shops carried out a test run of the bloomery for trip hammers. [2] The plant was commissioned 6 days later, on 24 November. [35] 1723 also saw the establishment of Yekaterinburg fortress , which would encompass many of the settlement's earliest buildings. Dmitry Mamin-Sibiryak very vividly described the beginning of the construction of a mining plant and a fortress: "Imagine completely deserted banks of the Iset river, covered with forest. In the spring of 1723, soldiers from Tobolsk, peasants of the assigned settlements, hired craftsmen appeared, and everything around came to life, as if by the dictates of a fairy tale. They dropped the forest, prepared a place for the dam, laid blast furnaces, raised the rampart, set up barracks and houses for the authorities... ". [36]

In 1722–1726 the Verkhne-Uktussky mining plant was built, [37] which was officially called the plant of the princess Elizabeth (the future village of Elizabeth, or Elizavetinskoe) and became a part of modern Yekaterinburg in 1934. [38] In 1726, Wilhelm de Gennin founded an auxiliary Verkh-Isetsky plant with a working settlement 2 versts from Yekaterinburg upstream ('verkh' in Russian) the Iset River. [39] The plant's dam formed the Verkh-Isetsky pond. Colloquially called by the Russian acronym VIZ, it was a satellite town until in 1926, with a population of over 20,000 people by this time, it was incorporated into Yekaterinburg as the core of the Verkh-Isetsky district. [39]

Yekaterinburg was one of the industrial cities of Russia prompted at the beginning of the 18th century by decrees of Tsar Peter the Great which demanded the development of the metalworking industry. With extensive use of iron, the city was built to a regular square plan with ironworks and residential buildings at the centre. These were surrounded by fortified walls so that Yekaterinburg was at the same time both a manufacturing centre and a fortress at the frontier between Europe and Asia. It, therefore, found itself at the heart of Russia's strategy for further development of the entire Ural region. The so-called Siberian Route became operational in 1763 and placed the city on an increasingly important transit route, which led to its development as a focus of trade and commerce between east and west, and gave rise to the description of the city as the "window to Asia". With the growth in trade and the city's administrative importance, the ironworks became less critical, and the more important buildings were increasingly built using expensive stone. Small manufacturing and trading businesses proliferated. In 1781 Russia's empress, Catherine the Great, granted Yekaterinburg town status and nominated it as the administrative centre for the wider region within Perm Governorate . [3] In 1807, the role of the capital of the mining and smelting region was confirmed by assigning it the status of the only "mountain city" in Russia. Until 1863, Yekaterinburg remained subordinate to the head of the mining plants of the Ural ridge , the minister of finance and personally to the emperor, and enjoyed considerable freedom from the governor's power. Since the 1830s, mountainous Yekaterinburg has become the center of mechanical engineering. [36]

In 1820–1845, 45% of the world's gold was mined in Yekaterinburg. This is the first ever "Gold Rush". [40] Until 1876, 80% of the coins in circulation in the Russian Empire were produced at the Yekaterinburg mint. [41]

Following the October Revolution , the family of deposed Tsar Nicholas II was sent to internal exile in Yekaterinburg where they were imprisoned in the Ipatiev House in the city. In July 1918, the Czechoslovak Legions were closing on Yekaterinburg. In the early hours of the morning of 17 July, the deposed Tsar, his wife Alexandra , and their children Grand Duchesses Olga , Tatiana , Maria , Anastasia , and Tsarevich Alexei were murdered by the Bolsheviks at the Ipatiev House. Other members of the Romanov family were killed at Alapayevsk later the same day. The Legions arrived less than a week later and captured the city. [42] [43] The city remained under the control of the White movement in which a provisional government was established. The Red Army took back the city and restored Soviet authority on 14 July 1919. [44] [45]

In the years following the Russian Revolution and the Russian Civil War , political authority of the Urals was transferred from Perm to Yekaterinburg. On 19 October 1920, Yekaterinburg established its first university, the Ural State University , as well as polytechnic, pedagogical, and medical institutions under the decree of Soviet leader Vladimir Lenin . Enterprises in the city ravaged by the war were nationalised, including: the Metalist (formerly Yates) Plant, the Verkh-Isetsky (formerly Yakovleva) Plant, and the Lenin flax-spinning factory (formerly Makarov). In 1924, the city of Yekaterinburg was renamed Sverdlovsk after the Bolshevik leader Yakov Sverdlov . [46] [28] [44]

By the 1934, following a series of administrative reforms carried by the early Soviet government, the earliest Russian settlements which predated Yekaterinburg and laid the basis of its founding, were incorporated into the city proper. [38] [47]

During the reign of Stalin, Sverdlovsk was one of several places developed by the Soviet government as a centre of heavy industry. Old factories were reconstructed and new large factories were built, especially those specialised in machine-building and metalworking. These plants included Magnitogorsk and the Chelyabinsk Tractor Plant in Chelyabinsk oblast , and Uralmash in Sverdlovsk. During this time, the population of Sverdlovsk tripled in size, and it became one of the fastest-growing cities of the Soviet Union. At that time, very large powers were given to the regional authorities. By the end of the 1930s, there were 140 industrial enterprises, 25 research institutes, and 12 higher education institutions in Sverdlovsk. [48] [49]

During World War II, the city became the headquarters of the Ural Military District on the basis of which more than 500 different military units and formations were formed, including the 22nd Army and the Ural Volunteer Tank Corps. Uralmash became the main production site for armoured vehicles. Many state technical institutions and whole factories were relocated to Sverdlovsk away from cities affected by war (mostly Moscow), with many of them staying in Sverdlovsk after the victory. The Hermitage Museum collections were also partly evacuated from Leningrad to Sverdlovsk in July 1941 and remained there until October 1945. [50] In the postwar years, new industrial and agricultural enterprises were put into operation and massive housing construction began. [51] [44] The lookalike five-story apartment blocks that remain today in Kirovsky, Chkalovsky, and other residential areas of Sverdlovsk sprang up in the 1960s, under the direction of Nikita Khrushchev 's government. [52] In 1977, Ipatiev House was demolished by order of Boris Yeltsin in accordance to a resolution from the Politburo in order to prevent it from being used as a rallying location for monarchists . Yeltsin later became the first President of Russia and represented the people at the funeral of the former Tsar in 1998. [53] There was an anthrax outbreak in Sverdlovsk in April and May 1979, which was attributed to a release from the Sverdlovsk-19 military facility . [54]

During the 1991 coup d'état attempt , Sverdlovsk, the home city of President Boris Yeltsin, was selected by him as a temporary reserve capital for the Russian Federation, in case Moscow became too dangerous for the Russian government. A reserve cabinet headed by Oleg Lobov was sent to the city, where Yeltsin enjoyed strong popular support at that time. [55] Shortly after the failure of the coup and subsequent dissolution of the Soviet Union, the city regained its historical name of Yekaterinburg on 23 September 1991. However, Sverdlovsk Oblast, of which Yekaterinburg is the administrative centre, kept its name. [56] [57]

In the 2000s, an intensive growth of trade, business, and tourism began in Yekaterinburg. In 2003, Russian President Vladimir Putin and German Chancellor Gerhard Schröder negotiated in Yekaterinburg. On 15–17 June 2009, the SCO and BRIC summits were held in Yekaterinburg, which greatly improved the economic, cultural, and tourist situation in the city. On 13–16 July 2010, a meeting between Russian President Dmitry Medvedev and German Chancellor Angela Merkel took place in the city. [58]

In 2018, Yekaterinburg hosted four matches of the 2018 FIFA World Cup and hosted the inaugural University International Sports Festival in 2023. [59]

Geographically, Yekaterinburg is in North Asia, close to the Ural Mountains (which divide Europe from Asia), 1,667   km (1,036   mi) east of the nation's capital Moscow.

The city has a total area of 1,111   km 2 (429   sq   mi) .

Yekaterinburg is on the eastern side of the Urals. The city is surrounded by wooded hills, partially cultivated for agricultural purposes. Yekaterinburg is located on a natural watershed, so there would be many bodies of water close and in the city. The city is bisected by the Iset River , which flows from the Urals into the Tobol River . There are two lakes in the city, Lake Shuvakish and Lake Shartash. The city borders Verkh-Isetskiy Pond, through which the Iset River flows. Lake Isetskoye and Lake Baltym are both near the city, with Lake Isetskoye located near Sredneuralsk , and Lake Baltym located near the towns of Sanatornyy and Baltym.

Yekaterinburg uses the Yekaterinburg Time, which is five hours ahead of UTC (UTC+5), and two hours ahead of Moscow Time . [60]

The city possesses a humid continental climate ( Dfb ) under the Köppen climate classification . [61] It is characterised by sharp variability in weather conditions, with well-marked seasons. The Ural Mountains, despite their insignificant height, block air from the west, from the European part of Russia. As a result, the Central Urals are open to the invasion of cold arctic air and continental air from the West Siberian Plain. Equally, warm air masses from the Caspian Sea and the deserts of Central Asia can freely penetrate from the south. Therefore, the weather in Yekaterinburg is characterised by sharp temperature fluctuations and weather anomalies: in winter, from frost at −40   °C to thaw and rain; in summer, from frosts to temperatures above 35   °C (95   °F) . [61]

The distribution of precipitation is determined by the circulation of air masses, relief, and air temperatures. The main part of the precipitation is brought by cyclones with a western air mass transfer, that is, from the European part of Russia, while their average annual amount is 601   mm. The maximum falls on a warm season, during which about 60–70% of the annual amount falls. For the winter period is characterized by snow cover with an average capacity of 40–50   cm. The coefficient of moistening(the ratio of yearly precipitation and potential evaporation ) – 1. [61]

• The average temperature in January is −12.6   °C (9.3   °F) . The record minimum temperature is −44.6   °C (−48.3   °F) (6 January 1915);
• The average July temperature is 18.9   °C (66.0   °F) . The record maximum temperature is 40.0   °C (104.0   °F) (11 July 2023);
• The average annual temperature is 2.1   °C (35.8   °F) ;
• The average annual wind speed is 2.9   m/s (10   km/h; 6.5   mph) ;
• The average annual humidity is 75%;
• The average annual precipitation is 534   mm (21.0   in) ;

According to the results of the 2021 Census , the population of Yekaterinburg was 1,544,376 ; [64] up from 1,349,772 recorded in the 2010 Census . [7]

As of 2021, the ethnic composition of Yekaterinburg was: [65]

Christianity is the predominant religion in the city, of which most are adherents to the Russian Orthodox Church. The Yekaterinburg and Verkhotursky diocese is located in the Holy Trinity Cathedral in the city. Other religions practised in Yekaterinburg include Islam , Old Believers , Catholicism , Protestantism , and Judaism .

Yekaterinburg has a significant Muslim community, but it suffers from a lack of worship space: there are only two small mosques . Another mosque was built in the nearby city of Verkhnyaya Pyshma . On 24 November 2007, the first stone was laid in the construction of a large Cathedral Mosque with four minarets , and space for 2,500 parishioners in the immediate vicinity of the cathedral and a synagogue , thus forming the "area of the three religions". [66] The mosque was planned to be built for the SCO summit, but due to funding problems, construction did not move from zero and is now frozen.

Construction of a Methodist church started in 1992, and with the help of American donations, finished in 2001. [67] A synagogue was opened in 2005, on the same place a 19th-century synagogue was demolished in 1962.

Most of the city's religious buildings were destroyed during the Soviet era, in addition to the synagogue, the three largest Orthodox churches in Yekaterinburg were demolished – the Epiphany Cathedral, the Ekaterininsky Cathedral, and the Great Zlatoust Church . Other Christian churches such as the Lutheran Church of Yekaterinburg and the Roman Catholic Church of St. Anne (a new Catholic St. Anne's Church was built in 2000) were demolished as well. Other churches were used as warehouses and industrial sites. The only religious building in Yekaterinburg in the Soviet era was the Cathedral of St. John the Baptist. Recently, some churches are being rebuilt. Since 2006, according to the surviving drawings, the Great Zlatoust Church was restored in 2012. On 17 April 2010, the city was visited by Patriarch Kirill . [68]

Yekaterinburg is the administrative centre of Sverdlovsk Oblast . [1] Within the framework of the administrative divisions , it is, together with twenty-nine rural localities , incorporated as the City of Yekaterinburg, [9] an administrative unit with the status equal to that of the districts . [1] As a municipal division, the City of Yekaterinburg is incorporated as Yekaterinburg Urban Okrug. [10]

Each district is not a municipal formation, and the historical centre of the city is divided into five inner-city districts (except Chkalovsky and Ordzhonikidzevsky).

A district named Akademicheskiy was formed from the parts of Leninsky and Verkh-Isetsky districts on 3 January 2020. [70] On 1 October 2021, more settlements were transferred from Verkh-Isetsky to Akademicheskiy district. [71]

The Charter of Yekaterinburg establishes a four-link system for the organisation of local authorities, which includes: the Head of Yekaterinburg, who serves as the chairman of the Yekaterinburg City Duma, the Yekaterinburg City Duma, the Administration of the City of Yekaterinburg, and the Chamber of Accounts. [74]

According to the charter of Yekaterinburg, the highest official of the municipal formation is the mayor of Yekaterinburg. The mayor is elected by universal suffrage, but since 3 April 2018, the procedure for direct elections of the mayor of the City of Yekaterinburg was abolished. The mayor of the city is endowed with representative powers and powers to organize activities and guide the activities of the City Duma. In addition, the mayor of the city exercises other powers such as concluding a contract with the head of the city administration and ensuring compliance with the Russian Constitution, Russian legislation, the city charter, and other normative acts. [75] [76]

In the event of a temporary absence of the mayor of Yekaterinburg, his authority under his written order is exercised by the deputy mayor of Yekaterinburg. [77]

The representative body of the municipal formation is the Yekaterinburg City Duma, which represents the city's entire population. The membership of the Duma is 36 deputies (18 deputies were elected in single-mandate constituencies and 18 in a single electoral district). Residents of the city elect deputies on the basis of universal suffrage for a period of 5 years. [74]

The executive and administrative body of the municipal formation is the Administration of the City of Yekaterinburg, led by the head of the Administration, currently held by Aleksandr Yacob. The administration is endowed with its own powers to resolve issues of local importance, but it is under the control and accountable to the Yekaterinburg City Duma. The building of the Administration of Yekaterinburg is located on 1905 Square . [76]

The Chamber of Accounts is a permanently operating body of external municipal financial control. The Chamber is formed by the apparatus of the City Duma and is accountable to it. The Chamber consists of the chairman, deputy chairman, auditors and staff. The structure and number of staff of the chamber, including the number of auditors, is determined by the decision of the City Duma. The term of office of the Chamber staff is 5 years. The Chamber of Accounts is a legal entity. [77]

In accordance with the regional charter, Yekaterinburg is the administrative centre of the Sverdlovsk Oblast. [1] The executive power is exercised by the governor of Sverdlovsk Oblast, the legislative power by the legislative assembly of Sverdlovsk Oblast, and the judicial power by the Sverdlovsk Regional Court, located in the building of the Palace of Justice. [78] The building serving the regional government is the White House and the building serving the legislative assembly is located next to it on October Square. The ministries of the Sverdlovsk Region are located in the building of the regional government, as well as in other separate buildings of the city. [79]

Yekaterinburg serves as the centre of the Ural Federal District. As a result, it serves as the residence of the presidential envoy , the highest official of the district and part of the administration of the President of Russia. The residence is located the building of the regional government on October Square near the Iset River embankment.

In addition, Yekaterinburg serves as the centre of the Central Military District and more than 30 territorial branches of the federal executive bodies, whose jurisdiction extends not only to Sverdlovsk Oblast, but also to other regions in the Ural Mountains, Siberia, and the Volga Region.

According to the results of the September 2013 elections, the mayor of the city was Yevgeny Roizman , nominated by the Civil Platform party. Out of the 36 seats in the City Duma, 21 belong to United Russia , 7 to A Just Russia , 3 to the Civil Platform, 2 to the Communist Party and 1 seat to the LDPR . The turnout in the mayoral elections was 33.57%. [80]

It was the last popular vote in Yekaterinburg. Since 2018, there have been no elections, but a vote in the Municipal Duma. On 25 September 2018 the majority of the representatives in the Duma voted in favour of the Vice-Governor of Sverdlovsk oblast, Alexander Vysokinskiy.

Yekaterinburg is one of the largest economic centres in Russia. It is included in the City-600 list (it unites the 600 largest cities in the world that produce 60% of global GDP), compiled by the McKinsey Global Institute, a research organisation. In 2010, the consulting company estimated the gross product of Yekaterinburg to be about $19   billion (according to the calculations of the company, it should grow to $40   billion by 2025). [82] [83]

By volume of the economy, Yekaterinburg ranks third in the country, after Moscow and St. Petersburg. According to a research of the Institute for Urban Economics, in the ranking of the largest cities and regional capital cities according to economic standards for 2015, Yekaterinburg ranked third. The city's gross urban product (GVP) was 898   billion rubles. Per capita GDP was 621.0 thousand rubles (18th place). [84] In 2015, the gross urban product of the Yekaterinburg metropolitan area amounted to 50.7   billion international dollars (the fourth place in the country) or 25.4 thousand international dollars in terms of per inhabitant of the metropolitan area. [85]

In the Soviet era, Yekaterinburg (as Sverdlovsk) was a purely industrial city, with a share of industry in the economy of 90% (of which 90% were in defense production). With Chelyabinsk and Perm, the three cities formed what to be the Urals industrial hub. [86]

The former head of Yekaterinburg, Arkady Chernetsky, has set the goal of diversifying the city's economy, which has resulted in the development of sectors such as warehousing, transportation, logistics, telecommunications, financial sector, wholesale and retail trade, etc. in Yekaterinburg. [86] Economist-geographer Natalia Zubarevich points out that at the present stage, Yekaterinburg has practically lost its industrial specialisation. [87]

The standard of living in Yekaterinburg exceeds the average standard across Russia. According to the Department of Sociology of the Financial University under the Government of the Russian Federation, it is among the top ten cities with the highest standard of living. Compared to other Russian cities with a population of around or over one million, in 2015, Yekaterinburg held a leading position in terms of average monthly wages and retail turnover, in terms of the total volume of investments in fourth place of fixed assets, and second place in housing placement. [88] [89]

The average monthly wage in Yekaterinburg following the results of 2019 was 54,976 rubles. This is the first place among the millionth municipalities of the Russian Federation. [90] There are on average 440,300 people employed by large and middle-sized organisations and companies. The unemployment rate at the end of 2015 was 0.83% of the total economically active population. Locals labelled the main problems of the city such the current state of the healthcare system, housing system, and transportation system. [89] [91]

The budget of Yekaterinburg in 2015 was executed on income in the amount of 32,063.6   million rubles, for expenses in the amount of 32,745.8   million rubles. Among the budget expenditures: 17 billion rubles were spent on education, over 1 billion rubles on culture, and about 900 million rubles on health. The main part of the revenue of the city treasury was its own tax and non-tax revenues (more than 18 billion rubles). The revenues from the regional and federal budgets were at the lowest level in 10 years. Specialists noted a decrease in tax revenues and an increase in tax debt (exceeded 2 billion rubles). [89] [92]

The main budget expenditures are the development of the economy (which accounts for 19% of expenditures) and the social security of the townspeople (11% of expenditures go). Cities such as Perm, Kazan and Ufa, spend for these purposes in a smaller percentage of costs (from 2 to 6%). Also, a fairly strict budgetary discipline is noted—the budget deficit is kept at the level of 2% of its volume. [93]

Yekaterinburg is one of the largest financial and business centres in Russia, with offices of multinational corporations, representative offices of foreign companies, and a large number of federal and regional financial and credit organisations. The financial market of Yekaterinburg is characterised by stability and independence, based both on the broad presence of large foreign and Moscow credit organisations and on the availability of large and stable local financial holdings. [94]

The financial sector of Yekaterinburg has more than 100 banks, including 11 foreign banks. The list of the largest Russian banks for assets for 2016 included 10 banks registered in Yekaterinburg, including but not all: Ural Bank for Reconstruction and Development, SKB-Bank, Uraltransbank, and UM Bank. [95] [96]

IT "SKB Kontur" from Yekaterinburg – the largest software manufacturer in Russia – first place according to the RAEX rating [97]

Also in Yekaterinburg is the Ural headquarters of the Central Bank of Russia. Since 7 August 2017, by order of the Bank of Russia, the branches of the Siberian, Far Eastern and part of the Prevolzhsky Federal Districts have been transferred to the control of the Ural Megaregal Directorate. Thus, this is one of the three main departments of the Mega-regulator in the territory of Russia. [98]

A major role in the formation of Yekaterinburg as a business centre has its infrastructural potential, which is growing at a high rate: transport accessibility for Russian and foreign economic entities, the availability of hotels, advanced communication services, business related services (consulting, exhibition activities, etc.). [94] Yekaterinburg has its own central business district, Yekaterinburg City. [99]

Yekaterinburg has been a major industrial centre since its foundation. In the 18th century, the main branches were smelting and processing of metal. Since the beginning of the 19th century, machine building appeared, and in the second half of the 19th century, light and food (especially milling) industry was widely spread. A new stage in the development of production occurred during the period of industrialisation – at this time in the city, factories were built, which determined the industry specialisation of heavy engineering. During World War II, Yekaterinburg (as Sverdlovsk) hosted about sixty enterprises evacuated from Central Russia and Ukraine. As a result, there was a sharp increase in the production capacity of existing plants and the emergence of new branches of the Urals industry.

At present, more than 220 large and medium-sized enterprises are registered in Yekaterinburg, 197 of them in manufacturing industries. [94] In 2015, they shipped 323,288 million rubles worth of own-produced goods. Production by industry was divided accordingly: metallurgical production and metalworking 20.9%, food production 13.3%, production of electrical equipment, electronic and optical equipment 9.2%, production of vehicles 8.4%, production of machinery and equipment 6.4%, chemical production 5.5%, production of other nonmetallic mineral products 3.7%, production of rubber and plastic products 2.8%, pulp and paper production, publishing and printing 0.5%, and other 29.3%. [100]

Several headquarters of large Russian industrial companies are located in the city: IDGC of Urals, Enel Russia, Steel-Industrial Company, Russian Copper Company, Kalina, NLMK-Sort, VIZ-Stal, Sinara Group, Uralelectrotyazhmash, Automation Association named after academician NA Semikhatov, Ural Heavy Machinery Plant (Uralmash), Fat Plant, Fores, confectionery association Sladko, Machine Building Plant named after M.I. Kalinin, Ural Turbine Plant, Uralkhimmash and others. [101]

Yekaterinburg ranks first in retail trade of the Russian Federation per capita, ahead of Moscow. [102] The consumer market contributes significantly to Yekaterinburg's economy. Revenue of retail stores in 2015 amounted to 725.9   billion rubles, and the number of retailers totaled 4,290. [103] As of 1 January 2016, 36 shopping centers operate in the city, taking up a total area of which was 1,502,700   m 2 (16,175,000   sq   ft) . The availability of shopping centres per 1,000 inhabitants increased to 597.2   m 2 (6,428   sq   ft) . [104]

Retail areas amounted to 2,019,000   m 2 (21,730,000   sq   ft) , with the availability of retail space reached 1,366.3   m 2 (14,707   sq   ft) per 1,000 inhabitants. According to these statistics, Yekaterinburg holds leading positions among other major cities of Russia. In the consumer market of Yekaterinburg, 1041 network operators are represented. The number of wholesale enterprises totalled 1,435. Among the Federal construction stores represented in the city, you can select: Leroy Merlin, [105] Castorama, [106] Domostroy, [107] Maxidom, [108] OBI, [109] Sdvor. [110] Yekaterinburg has an agricultural market named Shartashsky. [104] [111]

The revenue of catering in 2015 totalled 38.6   billion rubles. The network of catering enterprises in Yekaterinburg is presented as follows: 153 restaurants, 210 bars, 445 cafes, 100 coffee houses, 582 dining rooms, 189 eateries, 173 fast-food establishments, 10 tea shops, 319 other types of institutions (buffets, cafeterias, catering companies). 82.6% of catering enterprises provide additional services to consumers. [112]

The revenue of the services industry in 2015 totalled 74.9   billion rubles. The fastest pace in the city is developing hairdressing services, sewing and knitting atelier services, pawnshop services, fitness centre services. The network of public service enterprises in Yekaterinburg includes 5,185 facilities. In 2015, the provision of service areas for service enterprises totaled 382.1   m 2 (4,113   sq   ft) per 1,000 citizens. The highest concentration of household services is observed in the Verkh-Isetsky, Oktyabrsky and Leninsky districts. [113]

Greenwich Shopping Center, as of 2021, is the largest shopping center in Europe. [114]

The largest store in the world by area is Sima-Land. [115]

Yekaterinburg is a major centre for the Russian tourist industry. In 2015, the city was one of the top five most visited Russian cities (others being Moscow, St. Petersburg, Novosibirsk , and Vladivostok ) according to the Global Destinations Cities Index, which represents the payment system Mastercard . [116] In recent years, a lot of work has been done to create a positive image of Yekaterinburg as a centre for international tourism, including holding of summits for the Shanghai Cooperation Organisation (SCO) in 2008 and 2009 and the international exhibition Innoprom in 2009 and 2010. [117] In 2014, Yekaterinburg ranked third among Russian cities in popularity among foreign tourists after Moscow and St. Petersburg. [118]

In 2015, the total flow of inbound tourism grew by 10% compared to the previous year and amounted to 2.1   million people. [119] In recent years, there has been a tendency to reduce the role of business tourism in the overall flow: if in 2013 about 80% of trips were business, in 2015 their number was already 67%. Most tourists go to "bow to the memory of the last [czar] and his family." In addition, new tourist ideas are developing such as the Bazhov theme, the geological and mineralogical theme, industrial tourism, and the event calendar. [120]

Yekaterinburg is the third largest transport hub of Russia, behind Moscow and St. Petersburg. The city has 6 federal highways, 7 main railway lines, and an international airport. The location of Yekaterinburg in the central part of the region allows for 7 to 10 hours to get from it to any large city of the Urals. [121] The formation of Yekaterinburg as an important transportation hub is largely due to the city's favourable geographical location on a low stretch of the Ural Mountains, through which it was convenient to lay the main roads connecting the European and Eastern parts of Russia. [122]

Yekaterinburg is one of the ten Russian megacities with the largest car fleet (0.437 megacars were registered in the city in 2014), which has been intensively increasing in recent years (by 6–14% annually). [123] [124] The level of car ownership in 2015 has reached 410 cars per 1,000 people. [125] Its pace in the past few years has seriously exceeded the pace of development and the capacity of the road infrastructure. For the first time, transport problems started to appear in Yekaterinburg in the 1980s and though it did not seem threatening at first, the situation gets worse every year. Studies have shown that as early as 2005, the capacity limit for the road network was reached, which has now led to permanent congestion. [126] To increase the capacity of the street-road network, stage-by-stage reconstruction of streets is being carried out, as well as multi-level interchanges being built. In order to reduce the transit traffic, the Sverdlovsk Oblast administration announced two road projects in 2014: the Yekaterinburg Ring Road (EKAD) and an overpass road on Sovetskaya Street. The Yekaterinburg Ring Road would surround the largest municipalities of Yekaterinburg. Its purpose would be to help the city's economy and reduce traffic on the Middle Ring Road of the city, making it easier for civilians to commute around the city than going through the city's traffic congestion. Eventually, the Ring Road would connect to other federal roads in order for easier access between other Russian cities. Construction of the road started in the same year. The projects were assigned to the Ministry of Transport and Communications since the projects were crucial to the city's economy. Officials hope the road projects will build environments more conducive to improving local quality of life and outside investments. Completing these major inter-regional roads will increase productive traffic by 50% to 100%, improving the local economy with its ease of access to industries. [127]

Since 2014, the project for the introduction of paid parking in the central part of Yekaterinburg is being implemented. The project is implemented in parallel with the increase in the number of intercepting parking lots and the construction of parking lots. At the end of 2015, in the central part of the city there were 2,307 paid parking places. [125]

The total length of the road network in Yekaterinburg is 1,311.5   km (814.9   mi) , of which 929.8   km (577.8   mi) is cobbled carriageways, 880   km (550   mi) is with upgraded coverage, 632   km (393   mi) is backbone networks, of which 155   km (96   mi) are on the citywide backbone network movement. 20 interchanges have been constructed at different levels within the city limits, including 11 on the EKAD and 9 on the middle ring. 74 transport facilities (27 bridges across the Iset River, Patrushikha, Mostovka, Istok Rivers, 13 dams on the Iset, Patrushikha, Istok, Olkhovka, Warm, Shilovka Rivers, 23 road overpasses , and 18 out-of-the-way pedestrian crossings) were built as well. [128]

Yekaterinburg is served by the following highways: [129]

Yekaterinburg uses almost all types of public transport. The largest transportation services—the Municipal Association of Bus Enterprises, the Tram-Trolleybus Office, and the Yekaterinburg Metro —transported 207.4   million people in 2015. [130] The total volume of passenger transportation by all land transport modes decreases annually. If the annual passenger traffic of municipal transport was 647.1   million people in 2002, and according to this index the city occupied the third place in the country with a wide margin, then in 2008 this figure would be 412 million people (the fourth place in Russia). [131] [132]

Since 1991, the city operates the sixth metro in Russia and the thirteenth in the CIS . At the moment there is one line with 9 stations. In 2015 49.9   million passengers were transported; according to this metric the Yekaterinburg Metro is the fourth in Russia, behind the Moscow Metro, Saint Petersburg Metro, and Novosibirsk Metro . [133] Although the metro is the second most popular type of public transport, in recent years significant problems have appeared in its work: loss-making, obsolete rolling stock, and a shortage of funds for modernisation. [134] The tram network was established in 1929 and currently [ when? ] plays a leading role in the urban transport system. The volume of passengers carried for 2013 is 127.8   million, [135] but this declines every year (245   million people in 2013 [136] ). In 2016 there were 30 routes operating 459 cars. The total length of the tracks is 185.5   km. As of 2016 [ update ] , the construction of a tram line "Ekaterinburg-Verkhnyaya Pyshma" was planned. [137]

There are 93 bus routes operating in Yekaterinburg, including 30 municipal ones (EMUP "MOAP"). [138] In 2007, 114.5   million passengers were transported by municipal intercity buses (124.6   million in 2006). [139] The decrease in volume is due to the increasing role of the fixed-route taxis in the urban transport system of Yekaterinburg, as well as the high cost of travel. However, the city bus transport network provides significant employment for the people of Ekaterinburg, including the formidable babushkas who collect passenger fares. In the park of EMPU, there are 537 buses. [140] In 2013, there are 19 routes, which employ 250 trolleybuses. The total length of trolleybus lines is 168.4   km. The number of passengers transported by trolleybus in 2007 amounted to 78.4   million (84.3   million in 2006). [139]

In addition, the city operates an electric train route linking the north-western and the southern parts of Yekaterinburg, from Sem' Klyuchey to Elizavet.

Yekaterinburg is a major railway junction. In the Yekaterinburg node, 7 main lines converge (to Perm , Tyumen , Kazan , Nizhny Tagil , Chelyabinsk , Kurgan , and Tavda ). The Sverdlovsk Railway Administration is located in the city, which serves trains on the territory of the Sverdlovsk and Tyumen Regions, the Perm Territory, the Khanty-Mansiysk and Yamalo-Nenets Autonomous Districts, as well as parts of the Omsk Region, and there is a single road traffic control centre. The Perm–Yekaterinburg–Tyumen section is now part of the main route of the Trans-Siberian Railway .

Yekaterinburg is served by two primary airports: Koltsovo International Airport (SVX) and the smaller Yekaterinburg Aramil Airport . Koltsovo Airport is one of the largest airports in the country, serving 5.404   million passengers (including 3.485   million serviced by domestic airlines, 1.919   million at international flights) in 2017, making it the sixth busiest airport in Russia . [141]

Yekaterinburg has an extensive network of municipal, regional and federal health facilities. There are 54 hospitals, designed at a capacity of 18,200 beds, [142] 272 ambulatory polyclinics, and 156 dental clinics and offices. [143] Some health facilities are based on medical research institutes such as the Research Institute of Phthisiopulmonology, [144] the Research Institute of Dermatology and Immunopathology, [145] and the Ural State Medical University, as well as others.

In clean areas of the city, there is the Yekaterinburg Medical Centre, which includes the Sverdlovsk Regional Clinical Hospital No. 1 (also includes a polyclinic and a boarding house), Central City Hospital No. 40 (polyclinic, therapeutic building, surgical building, infectious body, neuro-surgical building, maternity hospital), Regional Cardiology Centre, Centre for Prevention and Control of AIDS, and MNTK Eye Microsurgery. [146]

Other large medical centres are the Uralmash Health Centre (Hospital No. 14), the Hospital of veterans of the Great Patriotic War, the district hospital of the Ministry of Internal Affairs, the district military hospital, the Oncology Centre, the Sverdlovsk Oblast Psychiatric Hospital, the Disaster Medicine Centre, the Sanguis Blood Transfusion Centre, children's versatile hospital No. 9, and the regional rehabilitation centre on Chusovsky lake. There are about 300 pharmacies in the city. [143] The number of doctors in public medical institutions is 11,339 people (83.9 per 10,000 people) and the number of nurses is 16,795 (124 per 10,000 people).

Private medical institutions also operate in the city. [147]

Yekaterinburg's education system includes institutions of all grades and conditions: preschool, general, special (correctional), and vocational (secondary and higher education), as well as others. Today, the city is one of the largest educational centres of Russia, with Yekaterinburg considered to be the leading educational and scientific centre of the Urals . [148]

There are 164 educational institutions in Yekaterinburg: 160 of them operate in the morning and the other 4 in the evening. In 2015, 133,800 people were enrolled in general education institutions, which holds a capacity of 173,161 people. [149] Yekaterinburg's education system also includes state pre-school educational institutions, non-state pre-school institutions, out-of-town health camps, and municipal city health facilities with a one-day stay. [150] Five educational institutions of the city: SUNC UrFU, Gymnasium No. 2, Gymnasium No. 9, Gymnasium No. 35, and Lyceum No. 135, were included in the rating of the five hundred best schools in the country by the Moscow Center for Continuous Mathematical Education and the Ministry of Education and Science of the Russian Federation . [151]

On 16 July 1914, the Ural Mining Institute of Emperor Nicholas II (now the Ural State Mining University ) was established as Yekaterinburg's first educational institution. [152] In 1930, the Sverdlovsk Power Engineering College (now the Ural Technical Institute of Communications and Informatics) was opened to train specialists in the field of communications. The Alexei Maximovich Gorky Ural State University (now the Ural Federal University ) became the first university in Yekaterinburg by decree of the Council of People's Commissars of the RSFSR , signed by Vladimir Lenin on 19 October 1920. The Sverdlovsk Engineering and Pedagogical Institute (today the Russian State Vocational and Pedagogical University) became the first university of the USSR for the training of engineering and pedagogical personnel when it was opened in 1979.

In terms of the level of qualification of the graduates, Yekaterinburg's universities are among the leading in Russia, in particular in terms of the number of graduates representing the current managing elite of the country, Yekaterinburg universities are second only to the educational institutions of Moscow and Saint Petersburg. [153] [154] Currently, there are 20 state universities in the city, which currently holds a total of 140,000 students. [155] In addition, there are 14 non-state institutions of higher education in the city, such as the Yekaterinburg Academy of Contemporary Art and the Yekaterinburg Theological Seminary. The prestigious architecture school, the Ural State Academy of Architecture and Arts , is also located within the city limits. Other institutions of higher education Ural State Pedagogical University, Ural State University of Forestry, Ural State University of Railway Transport, Ural State University of Economics, Military Institute of Artillery, Ural State Conservatory , Ural State Agricultural Academy, Ural State Law Academy , Ural State Medical University, Ural State Academy of Performing Arts, Ural Academy of Public Service, and Institute of International Relations .

In May 2011, the Ural State University and Ural State Technical University merged to form the Boris N. Yeltsin Ural Federal University , making it the largest university in the Urals and the largest university in Russia. As of 1 January 2016, the university had 35,300 students and 2,950 teachers. The university's budget in 2015 totalled 9,1   billion rubles and the volume of research and development work totalled 1,6   billion rubles. [156] As of 2021, UrFU is the largest university in Russia in terms of the number of students, being on the 351st place in the QS World University Rankings. [157] [158] The number of publications of the university in the Web of Science database is about a thousand per year. [159]

There are many branches of non-resident universities in the city, including the Ural branch of the Siberian State University of Telecommunications and Informatics, the Ural branch of the Russian Academy of Private Law, the Yekaterinburg branch of the Plekhanov Russian Economic Academy, the Yekaterinburg branch of the University of the Russian Academy of Education, the Yekaterinburg branch of the Moscow State University, and Sholokhov Humanitarian University, as well as others.

In Yekaterinburg, a large number of print publications are published: about 200 newspapers, the most read being the Ural Worker , Vecherny Yekaterinburg , Oblastnaya Gazeta , and For Change! , and 70 magazines, with most read being Red Burda and I'm Buying . [160] [161]

A television studio was built in Yekaterinburg (as Sverdlovsk) in 1955 and on 6 November of the same year, the first telecast appeared. Coloured television later appeared in 1976. [162] Now the television is broadcast by 19 companies, including but not all: STRC Ural, Channel Four, 41 Home, Channel 10, OTV, Union (Orthodox), and UFO 24. Broadcasting is carried out from the TV tower on Lunacharsky street (television studio GTRK Ural), the TV tower on the Moskovskiy Hill, and from the TV tower (radio relay tower) on Blyukher Street. In 1981, construction of a new television tower was started, which was to become the second tallest in Russia after the Ostankino Tower and cover the territory of most of the Sverdlovsk region, but economic difficulties postponed construction. As a result, the television tower was the tallest uncompleted structure in the world. On 24 March 2018, the television tower was demolished by detonation for the city's beautification in preparation of the 2018 FIFA World Cup . [163] The Shartash radio mast, which broadcasts, is the tallest structure in the city, with a height of 263 meters. [164] In addition, several dozens of national and local news agencies are broadcast in Yekaterinburg, with the most watched being ITAR-TASS Ural, RUIA-Ural, and Interfax-Ural.

At the moment [ when? ] , there are 26 internet providers and 6 cellular operators in the city. [165] According to Yekaterinburg News , the city has signed a cooperative agreement with the Russian mobile operator Vimpelcom , working under the Beeline brand. The partnership will involve cooperation on investment projects and social programmes focused on increasing access to mobile services in the city. Beeline has launched an initiative to provide Wi-Fi services in 500 public trams and trolley buses in Yekaterinburg. [166]

Yekaterinburg is a multipurpose cultural centre of the Urals Federal District. [148] There are about fifty libraries in the city. The largest library organisations are the Sverdlovsk Oblast Universal Scientific Library, the V.G. Belinsky Scientific Library, which is the largest public library in Sverdlovsk Oblast, and the Municipal Library Association, which is composed of 41 libraries throughout the city, including the AI Herzen Central City Library. [167]

There are about 50 different museums in the city. [168] Yekaterinburg has unique museum collections, such as the collections of Russian paintings in the Yekaterinburg Museum of Fine Arts and the Nevyansk icons in the Nevyansk Icon Museum , with more than 300 icons representing the eighteenth through the twentieth centuries on display. There is also a unique exhibit, the Kaslinsky cast iron pavilion, which received main awards at the 1900 World Exhibition in Paris. The Kasli Pavilion was registered by UNESCO as the only cast-iron architectural structure in the world, which is in the museum collection. [169] Museums of the city also have collections of jewellery and stone ornaments. The United Museum of Writers of the Urals presents exhibitions in memory of writers such as Dmitry Mamin-Sibiryak and Pavel Bazhov . It also is the home of the Shigirskaya Kladovaya ( Шигирская кладовая ), or Shigir Collection, which includes the oldest known wooden sculpture in the world. The sculpture was found near Nevyansk and originally estimated to have been made approximately 9,500 years ago, but now is estimated to have been made 11,500 years ago. [170] Yekaterinburg museums annually participate in the international event Long Night of Museums .

Yekaterinburg has the third most theatres in Russia. [171] The influence of theatrical life of the city was made by the Moscow Art Academic Theater and the Central Theater of the Soviet Army when they evacuated to Yekaterinburg (as Sverdlovsk) during World War II, and they had their own theater in the city. [172] Notable theatres that operate in the city are Academic Theater of Musical Comedy, Drama Theater, Kolyada-Theater , the youth theatre, and the puppet theatre, as well as others. The Yekaterinburg Opera and Ballet Theater received four awards at the Golden Mask 2020 Festival in Moscow, including the main Golden Mask for the Best Opera Performance [173]

In 2014, the city showcased its education, literary, art, and theatre culture through the Russian Year of Culture Programme. [174]

The city has a well-developed film industry. Opened back in 1909, Laurage was the first cinema in Yekaterinburg. In 1943, the Sverdlovsk Film Studio was opened and produced its first feature film Silva a year later. After the Second World War, the studio produced up to ten feature films a year. There are more than 20 cinemas in Yekaterinburg, the oldest of which is the Salyut, while the most capacious is the Cosmos spacecraft. [175] [176] There are also chains of movie theatres such as Premier-Zal, Kinomaks, and Kinoplex, which usually open in shopping and entertainment centres.

A number of popular Russian rock bands, such as Urfin Dzhyus, Chaif , Chicherina , Nautilus Pompilius , Nastya, Trek, Agata Kristi , Slaughter to Prevail and Smyslovye Gallyutsinatsii , were originally formed in Yekaterinburg ( Ural Rock is often considered as a particular variety of rock music. Yekaterinburg and St. Petersburg are actually considered to be the main centres of the genre in Russia). Also, opera singers like Boris Shtokolov , Yuri Gulyayev , Vera Bayeva graduated from the Urals State Conservatory. The Ural Philharmonic Orchestra (currently conducted by Dmitry Liss ), founded by Mark Paverman and located in Yekaterinburg, is also very popular in Russia and in Europe, as well as the Ural Academic Popular Chorus, a folk-singing and dance ensemble. [ citation needed ]

Yekaterinburg V. I. Filatov State Circus is located in the centre of the city, on the western bank of the Iset River. In 2012, the Yekaterinburg Circus was nominated "Best Circus of the Year" for the circus show Sharivari by the Rosgoscirk and the Ministry of Culture . [177]

The Presidential Center named after Boris Yeltsin was built in Yekaterinburg in 2015. It is considered to be a public, cultural and educational center. Center has its art gallery, library, museum equipped with the newest multimedia technologies that help to present the documents, video materials and archive photos. In 2017, the Yeltsin Center was recognized as the best museum in Europe by the Council of Europe, the first of the museums in Russia. [178]

The Urals Society of Natural Science Lovers pushed Yekaterinburg to have a zoo. Currently, the zoo has more than 1,000 animals that belong to more than 350 species. The zoo covers an area of 2.7 hectares.

On 18 June 2011, Yekaterinburg launched Red Line as a pedestrian tourist route for self-guided tours by residents and visitors to go to 34 landmarks in the historical section of the city. [179]

Many buildings of Yekaterinburg are ranged from a different number of architectural styles. The city had a regular layout, based on the fortresses of the Renaissance and by the principles of French town planning during the 17th century. By the 18th century, the Baroque movement was not that influential in Yekaterinburg, with the style being seen in churches which later declined [180]

In the first half of the 19th century, neoclassicism grew influential in the Yekaterinburg's architecture. The estates were built in the neoclassic style, including the main house, wings, services, and often an English-style park. This style's influence in Yekaterinburg is mostly due to the contributions of architect Michael Malakhov, who worked in the city from 1815 to 1842. He designed the assemblies of the Verkhne-Isetsky factory as well as the Novo-Tikhvinsky Monastery. [180]

At the beginning of the 20th century, eclecticism became a dominant influence in Yekaterinburg's architecture. Buildings such as the Opera House and Yekaterinburg railway station were built in this style. During the 1920s and the 1930s, constructivism took effect, influencing residential complexes, industrial buildings, stadiums, etc. Architects Moses Ginzburg, Jacob Kornfeld, the Vesnina brothers, Daniel Friedman, and Sigismund Dombrovsky contributed greatly to the constructivism in the city. More than 140 structures in Yekaterinburg are designed through the constructivist style. [181]

During the 1930s to 1950s, there was a turn back to neoclassicism, with much attention paid to public buildings and monuments. Notable examples include the buildings of the Ural Industrial Institute on Lenin Avenue, the City Party Committee and the City Council Executive Committee building (now the City Administrative building), the District Officers' House, and the House of Defense complex. Cultural buildings are built in the squares in orderly composition. In these years, architects Golubev, K. T. Babykin, Valenkov worked fruitfully in Yekaterinburg with this style. In the 1960s, changes in the approach to construction led to widespread distribution of apartment blocks common in the Khrushchev era . Buildings built by individuals were rare, among them being: KKT "Kosmos", the Palace of Youth, and DK UZTM. [182]

From the 1960s to the 1980s, as industrial development grew in Yekaterinburg, so did rationalism . The situation changed in the 1990s when Russia transferred into a market economy. At that time, older buildings were restored, giving the urban area a new environment such as: the Cosmos Concert Hall, the Puppet Theater, the children's ballet theatre The Nutcracker, the Palace of Justice, the Cathedral of the Blood, and the Church of the Transfiguration . At the same time, the construction of new buildings was accompanied by the demolition of historical buildings, leading to the development of the "facade" phenomenon, where the facades of historic buildings are preserved while adjacent modern buildings are built. [183]

The centre of Yekaterinburg became the centre of new construction, where banks, business centres, hotels, luxury residential complexes, and sports and shopping centres were built. High-tech architecture grew influential, with buildings such as the Center for Railway Transportation Management, the Summit business centre, the Aquamarine residential complex, and the retail strip at Vaynera Street being notable examples. Along with this, postmodernism revived interest in the older architectural styles of Yekaterinburg, growing more emphasis on historicalism and contextualism. In the late 1990s, architects grew interested in regionalism . [183]

At the beginning of the 21st century, Yekaterinburg architects turned back to the Soviet-based avant-garde, and influence future city buildings with the neoconstructivist style. The practice of attracting large foreign investors to projects has become popular. In 2007, the construction of the Central business district started, being headed by the French architect Jean Pistre. [183] In 2010, Yekaterinburg became one of the largest centers for the construction of High-rise buildings. In the city, 1,189 high-rise buildings were built, including 20 skyscrapers, the tallest of which is the Iset Tower , with a height of 209 meters. [184]

Yekaterinburg is also a leading sports centre in Russia. A large number of well-known athletes, both world and Olympics champions, are associated with the city. Since 1952, Yekaterinburg athletes have won 137 medals at the Olympic Games (46 gold, 60 silver and 31 bronze). In the 2008 Summer Olympics , 8 residents of Yekaterinburg returned with medals (1 gold, 3 silver and 4 bronze). [185]

In 1965, Yekaterinburg (as Sverdlovsk), along with a number of Russian cities, hosted the Bandy World Championship . In 2018, Yekaterinburg was one of the 11 Russian cities that hosted the 2018 FIFA World Cup. The matches were played on the upgraded Yekaterinburg Arena (called Central Stadium before the World Cup). [186]

Yekaterinburg has a total of 1728 sports facilities, including 16 stadiums with stands, 440 indoor gyms and 45 swimming pools. There are 38 sports children's and youth schools for reserves for the Olympic Games, in which more than 30,000 people are participating. [187]

Sport clubs

Yekaterinburg has many professional sports clubs in sports such as volleyball, basketball, futsal , bandy , and ice hockey for both women and men. Bandy club SKA-Sverdlovsk , women's volleyball club VC Uralochka-NTMK , women's basketball club UMMC Yekaterinburg , and futsal club MFK Sinara Yekaterinburg were among the best teams in Russia and Europe.

2018 FIFA World Cup

Yekaterinburg hosted four matches of the 2018 FIFA World Cup [59] Yekaterinburg is one of the 11 Russian cities that hosted the 2018 FIFA World Cup. The matches were played on the upgraded Yekaterinburg Arena . [186]

For the World Cup 2018, from 7 October 2015 to 29 December 2017, the Central Stadium was upgraded to bring it into compliance with FIFA requirements for the World Cup and was renamed Yekaterinburg Arena. The architectural concept of the new stadium is built on a combination of historical walls and the built-in core of the modern arena. During the reconstruction of the sports facility, which is a monument of history and culture, the facades are carefully preserved, and the arena itself is equipped with the latest technical achievements of the sports industry. Temporary stands extending outside the stadium's original perimeter were erected to comply with the FIFA requirement of seating for 35,000 spectators. They can hold a total of 12,000 spectators, but the seating will be removed after the World Cup, decreasing the seating capacity back to 23,000. [188] [189]

The FIFA Fan Fest in Yekaterinburg is located in the Mayakovsky Central Park of Entertainment and Culture. Located just outside the city centre in a popular and well-known amusement park, it will have a capacity to hold 17,000 people. [190]

Koltsovo Airport was also reconstructed and had a second runway built. In addition, work was done to prepare another passenger terminal, modernize the technical infrastructure, and launch the business aviation hangar. The airport's capacity in preparation for the World Cup has increased to two thousand people per hour. The street and road network was also upgraded. [191]

The United States, [192] United Kingdom, [193] Germany, [194] France, [195] China [196] and several other countries have consulates in Yekaterinburg.

The BRIC countries met for their first official summit on 16 June 2009, in Yekaterinburg, [197] with Luiz Inácio Lula da Silva , Dmitry Medvedev , Manmohan Singh , and Hu Jintao , the respective leaders of Brazil, Russia, India and China, all attending.

The foreign ministers of the BRIC countries had also met in Yekaterinburg previously on 16 May 2008.

In June 2013, at the 153rd General Assembly of the Bureau of International Expositions held in Paris, representatives from Yekaterinburg presented the city's bid to host the 2020 World Expo . Yekaterinburg's concept for the upcoming exhibition relates to the impact of globalisation on the modern world.

Russian President Vladimir Putin confirmed during a televised statement in English to earmark the required funds to build an exhibition complex large enough to receive the estimated 30 million visitors from more than 150 countries. [198]

Yekaterinburg later bid for the Expo 2025 . Yekaterinburg's concept for the bid exhibition relates to the technologies to make people happy by changing the world with innovation and quality of life. The host was announced on 23 November 2018 and Yekaterinburg lost out to Osaka, Japan.

Yekaterinburg hosted the Global Summit on Manufacturing and Industrialization (GMIS — 2019) GMIS under the auspices of the United Nations. [199] The annual INNOPROM exhibition is among the five largest industrial exhibitions in the world. [200]

Yekaterinburg is twinned with: [201]

• Anton Bakov , Leader of the Monarchist Party
• Irina Antonenko , Miss Russia 2010
• Aleksei Balabanov , film director, screenwriter, producer
• Vera Bazarova , pairs figure skater
• Pavel Bazhov , folklorist and children's author
• Old Man Bukashkin , artist and poet
• Pavel Datsyuk , ice hockey player
• Nikolay Durakov , bandy legend
• Chiang Fang-liang , former first lady of Taiwan
• Aleksey Fedorchenko , film director, producer
• Denis Galimzyanov , sprinter cyclist
• Anna Gavrilenko , Group rhythmic gymnast Olympic Gold medalist
• Nikolay Karpol , national women volleyball team coach
• Nikolai Khabibulin , ice hockey player
• Alexei Yashin , ice hockey player
• Alexei Khvostenko , avant-garde poet, singer-songwriter, artist, and sculptor
• Nikolay Kolyada , actor, director, writer, playwright, and playwriting teacher
• Ilya Kormiltsev , poet, translator, publisher
• Olga Kotlyarova , Olympic runner
• Maxim Kovtun , figure skater
• Vladislav Krapivin , children's author
• Valeria Savinykh , WTA Professional player
• Nikolay Krasovsky , mathematician
• Yulia Lipnitskaya , figure skater
• Iskander Makhmudov , businessman
• Vladimir Malakhov , ice hockey player
• Gennady Mesyats , vice-president of the Russian Academy of Sciences
• Maxim Miroshkin , pairs figure skater
• Vladimir Mulyavin (1941 – 2003), Belarusian musician and the founder of the folk-rock band Pesniary [202]
• Alfia Nazmutdinova , rhythmic gymnast
• Ernst Neizvestny , sculptor
• Oleg Platonov , writer, historian, and economist
• Daria Pridannikova , rhythmic gymnast
• Eduard Rossel , ex-governor of Sverdlovsk Oblast
• Boris Ryzhy , poet
• Mikhail Shchennikov , race walker
• Vera Sessina , rhythmic gymnast
• Georgy Shishkin , painter
• Vassily Sigarev , playwright, screenwriter, film director
• Anastasiia Tatareva , Group rhythmic gymnast Olympic Gold medalist
• Sergei Tchepikov , Olympic biathlon competitor
• Vladimir Tretyakov , ex-rector of the Ural State University
• Lev Vainshtein , Olympic shooter
• Sergei Vonsovsky , physicist
• Alexander Dudoladov , writer
• Alexander Malinin , singer
• Petr Yan , Former UFC Bantamweight Champion
• A ballistic missile submarine of the Project 667BDRM Delfin class ( NATO reporting name: Delta IV ) is named Ekaterinburg (K-84/"807") in honour of the city.
• The asteroid 27736 Ekaterinburg was named in the city's honour on 1 June 2007.

Related Research Articles

Sverdlovsk Oblast is a federal subject of Russia located in the Ural Federal District. Its administrative center is the city of Yekaterinburg, formerly known as Sverdlovsk. Its population is 4,268,998.

Irbit is a town in Sverdlovsk Oblast, Russia, located 203 kilometers (126 mi) from Yekaterinburg by train or 250 kilometers (160 mi) by car, on the right bank of the Nitsa. Population: 37,009 (2021 Census) ; 38,357 (2010 Census) ; 43,318 (2002 Census) ; 51,708 (1989 Soviet census) .

Koltsovo International Airport is the international airport serving Yekaterinburg, Russia, located 16 km (10 mi) southeast of the city. Being the largest airport in Sverdlovsk Oblast, Koltsovo also serves nearby towns such as Aramil, Sysert, and Polevskoy. In general, the airport is responsible for serving approximately 4,290,000 people yearly. The airport is a hub for Ural Airlines, RusLine and Aviacon Zitotrans. Due to its location in the center of Russia, Yekaterinburg's airport is included in the "Priority Airports" list of Russia's Federal Air Transport Agency (Rosaviatsia).

Serov is a mining and commercial town in Sverdlovsk Oblast, Russia, located on the eastern foothills of the Ural Mountains, on the left bank of the Kakva River, about 350 kilometers (220 mi) north of Yekaterinburg. Population: 99,373 (2010 Census) ; 99,804 (2002 Census) ; 104,158 (1989 Soviet census) .

Pervouralsk is a city in Sverdlovsk Oblast, Russia, located on the Chusovaya River 39 kilometers (24 mi) west of Yekaterinburg, the administrative center of the oblast. Population: 124,528 (2010 Census) ; 132,277 (2002 Census) ; 142,193 (1989 Soviet census) ; 122,000 (1974); 90,000 (1959); 44,000 (1939).

Sredneuralsk is a town under the administrative jurisdiction of the Town of Verkhnyaya Pyshma in Sverdlovsk Oblast, Russia, located on the shore of Iset Lake, at the head of the Iset River, 25 kilometers (16 mi) north of Yekaterinburg. Population: 20,449 (2010 Census) ; 19,555 ; 18,786 (1989 Soviet census) .

Anton Alekseyevich Bakov is a Russian businessman, monarchist politician, traveler, writer and human rights activist. He is the chairman of the Russian Monarchist Party, was a member of the 4th convocation of the State Duma of Russia from 2003 to 2007 and was a candidate at 2018 Russian presidential election. Due to being known for a long series of unusual political projects such as Ural franc, the writer Alexei Ivanov coined him a "political Leonardo".

Alexander Sergeevich Misharin is the former governor of Sverdlovsk Oblast, a region in Russia. He was appointed in 2009 after resignation of the previous governor, Eduard Rossel and resigned on May 14, 2012. Prior to his governorship, he made a career in the railway industry, rising to Russia's Deputy Railway Minister. He was appointed first vice-president of Russian Railways and head of Skorostniye Magistrali, the Russian high-speed rail developer and operator on November 28, 2012.

Isetsky District is an administrative district (raion), one of the twenty-two in Tyumen Oblast, Russia. As a municipal division, it is incorporated as Isetsky Municipal District . It is located in the west of the oblast. The area of the district is 2,751 square kilometers (1,062 sq mi). Its administrative center is the rural locality of Isetskoye. Population: 26,061 ; 26,565 (2002 Census) ; 25,862 (1989 Soviet census) . The population of Isetskoye accounts for 28.7% of the district's total population.

Gostiny Dvor – is a shopping (merchant) center in the historical center of Kamensk-Uralsky, Sverdlovsk oblast.

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The Rail Bridge over the Iset River - is an experimental bridge over the Iset River is a unique engineering structure made according to the advanced technology of the late 1930s in Kamensk-Uralsky, Sverdlovsk oblast.

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The coat of arms of Yekaterinburg is the official municipal coat of arms of Yekaterinburg, Russia. The current symbol was adopted on 23 May 2008 and consists of a French shield divided horizontally into two fields, with a white mine shaft and a white furnace within the top field, which is green, and a blue wavy bend within the bottom field, which is gold. A gold bear and gold sable are located to the left and right of the shield, respectively. A gold crown with a gold laurel wreath is located above the shield and a gold ribbon is located below the shield. A grey druse is located at the bottom center of the shield.

Yevgeny Vladmirovich Kuyvashev is a Russian politician serving as Governor of Sverdlovsk Oblast since 29 May 2012. He served as the acting governor from 14 May 2012 to 29 May 2012, and again from 17 April 2017 to 18 September 2017.

Alexander Leonidovich Burkov is a Russian politician who served as governor of Omsk Oblast from 2017 to 2023. He is a member of the Central Council of A Just Russia — For Truth party.

The 2022 Sverdlovsk Oblast gubernatorial election took place on 11 September 2022, on common election day. Governor Yevgeny Kuyvashev was re-elected for a third term.

• 1 2 3 4 5 6 Law #30-OZ
• 1 2 3 Haywood, A. J. (2010). Siberia: A Cultural History , Oxford University Press, p.   32
• ↑ Charter of Yekaterinburg, Article   24.1
• ↑ Official website of Yekaterinburg. Alexander Edmundovich Yakob, Head of Administration of the City of Yekaterinburg Archived 12 July 2015 at the Wayback Machine (in Russian)
• ↑ "Проект о внесении изменений в Генеральный план развития городского округа – муниципального образования «город Екатеринбург» на период до 2025 года" (in Russian). p.   168. [ permanent dead link ]
• 1 2 Federal State Statistics Service (21 May 2004). Численность населения России, субъектов Российской Федерации в составе федеральных округов, районов, городских поселений, сельских населённых пунктов   – районных центров и сельских населённых пунктов с населением 3   тысячи и более человек [ Population of Russia, Its Federal Districts, Federal Subjects, Districts, Urban Localities, Rural Localities—Administrative Centers, and Rural Localities with Population of Over 3,000 ] (XLS) . Всероссийская перепись населения 2002   года [All-Russia Population Census of 2002] (in Russian).
• ↑ "Federal State Statistic Service" . Government of Russia. 1 January 2024 . Retrieved 6 June 2024 .
• 1 2 Государственный комитет Российской Федерации по статистике. Комитет Российской Федерации по стандартизации, метрологии и сертификации.   №ОК 019-95   1 января 1997 г. « Общероссийский классификатор объектов административно-территориального деления. Код   65 401 », в ред. изменения №278/2015 от   1 января 2016 г.. (State Statistics Committee of the Russian Federation. Committee of the Russian Federation on Standardization, Metrology, and Certification.   # OK 019-95   January   1, 1997 Russian Classification of Objects of Administrative Division (OKATO). Code   65 401 , as amended by the Amendment   # 278/2015 of   January   1, 2016. ).
• 1 2 3 Law #85-OZ
• ↑ "Об исчислении времени" . Официальный интернет-портал правовой информации (in Russian). 3 June 2011 . Retrieved 19 January 2019 .
• 1 2 "Срок регистрации домена закончился" . www.ekaterinburg.com . Archived from the original on 21 January 2013 . Retrieved 26 February 2022 .
• ↑ Upton, Clive ; Kretzschmar, William A. Jr. (2017). The Routledge Dictionary of Pronunciation for Current English (2nd   ed.). Routledge. p.   1552. ISBN   978-1-138-12566-7 .
• ↑ "RUSSIA: Ural'skij Federal'nyj Okrug: Ural Federal District" . City Population.de . 4 August 2020 . Retrieved 2 October 2020 .
• ↑ "Рейтинг столичных городов России от Фонда "Институт экономики города" " . Urbaneconomics.ru .
• ↑ Kolossov, Vladimir; Eckert, Denis (1 January 2007). "Russian regional capitals as new international actors: the case of Yekaterinburg and Rostov" . Belgeo (1): 115–132. doi : 10.4000/belgeo.11686 .
• ↑ "Central Asian Chapter by Eurasian Respiratory and Allergy Consortium" . Era-cac.org . Archived from the original on 12 June 2018 . Retrieved 1 June 2018 .
• ↑ "Yekaterinburg - Entertainment - Russia.com" . Russia.com .
• ↑ "Конструктивизм. Жемчужина архитектуры Екатеринбурга" . www.e1.ru (in Russian). 16 January 2018 . Retrieved 21 December 2021 .
• ↑ "Как Екатеринбург за 10 лет стал столицей конструктивизма" . Strelka Mag (in Russian). Archived from the original on 5 March 2021 . Retrieved 21 December 2021 .
• ↑ Урал, Наш (19 May 2016). "Советская утопия: эпоха конструктивизма в Екатеринбурге" . Наш Урал (in Russian) . Retrieved 21 December 2021 .
• ↑ "Все кругом храпят, а Екатеринбург — пробужденный Когда уральский город объявил себя российской столицей стрит-арта, многие смеялись. А потом он стал ею" . Meduza (in Russian) . Retrieved 21 December 2021 .
• ↑ "Как Екатеринбург становится столицей стрит-арта" . Российская газета (in Russian). 16 April 2019 . Retrieved 21 December 2021 .
• ↑ "Екатеринбург – столица стрит-арта. Часть первая" . www.uralweb.ru (in Russian). Archived from the original on 3 March 2021 . Retrieved 21 December 2021 .
• ↑ "Памятникик археологии" . 1723.ru . Retrieved 20 May 2018 .
• 1 2 "1.2. Палкинские каменные палатки. Проект 1. | "Образование Урала" " . uraledu.ru (in Russian). Archived from the original on 5 April 2012 . Retrieved 20 May 2018 .
• ↑ ГАМАЮНСКАЯ КУЛЬТУРА – Уральская Историческая Энциклопедия . ural.ru (in Russian). Archived from the original on 22 July 2014 . Retrieved 20 May 2018 .
• 1 2 3 4 5 6 "Екатеринбург" . Геральдика Свердловской области . Официальный сайт областной думы законодательного собрания. Archived from the original on 8 March 2013 . Retrieved 6 December 2009 .
• ↑ Юрий, Коновалов (26 March 2004). "Первые русские поселения на реке Уктус" . www.okorneva.ru (in Russian) . Retrieved 7 June 2024 .
• 1 2 Кулешов, Николай (2001). "Горных заводов щит" . Домострой (4).
• ↑ Архипова, Нина (2001). "Тайны "превысочайшего Камня" ". Родина (11).
• ↑ Корепанов Н. С. Уктус — исток Екатеринбурга — Екатеринбург: Грачёв и партнёры, 2012. — 40 экз. — ISBN 978-5-91256-129-0
• 1 2 3 4 5 Юхт, Александр (1985). Государственная деятельность В. Н. Татищева в 20-е — начале 30-х годов XVIII века (in Russian). Moscow: Наука .
• ↑ "Библиотека истории: Ремесло историка в России – Бердинских В.А." history-library.com . Archived from the original on 1 April 2019 . Retrieved 20 May 2018 .
• ↑ Завод-крепость – История основания Екатеринбурга – Информационный портал Екатеринбурга . ekburg.ru (in Russian) . Retrieved 20 May 2018 .
• 1 2 "Основание Екатеринбурга" . Histrf.ru . Retrieved 20 February 2022 .
• ↑ Металлургические заводы Урала XVII—XX вв.: Энциклопедия / глав. ред. В. В. Алексеев. — Екатеринбург   : Издательство «Академкнига», 2001.
• 1 2 ipravo.info. "О ликвидации Баженовского и Сысертского районов Уральской области и о расширении городской черты и пригородной зоны города Свердловска – Российский Правовой Портал" (in Russian). ipravo.info. Archived from the original on 19 June 2018 . Retrieved 19 June 2018 .
• 1 2 "History of the Verkh-Isetsky district" . Administration of Verkh-Isetsky district . Archived from the original on 16 December 2021 . Retrieved 7 June 2024 .
• ↑ "Золотой век Екатеринбурга" . Уралнаш. Интересно о Екатеринбурге . 9 October 2019. Archived from the original on 14 August 2021 . Retrieved 15 August 2021 .
• ↑ "50 интересных фактов об Екатеринбурге — Общенет" . obshe.net . Retrieved 15 August 2021 .
• ↑ Massie, Robert K. (22 February 2012). The Romanovs: The Final Chapter . Random House Publishing Group. ISBN   9780307873866 .
• ↑ "FSU News" . fsu.edu . Retrieved 15 May 2018 .
• 1 2 3 История Екатеринбурга – Информационный портал Екатеринбурга . ekburg.ru (in Russian) . Retrieved 20 May 2018 .
• ↑ "Временное Областное Правительство Урала – Энциклопедия Екатеринбурга – Энциклопедии & Словари" . enc-dic.com . Archived from the original on 20 May 2018 . Retrieved 20 May 2018 .
• ↑ Главная: НОВОСТИ . familii.ru (in Russian) . Retrieved 20 May 2018 .
• ↑ "Справочник по административно-территориальному делению Свердловской области" (PDF) . ГАСО (State Archive of the Sverdlovsk oblast). p.   37. Archived from the original (PDF) on 22 February 2017 . Retrieved 2 February 2013 .
• ↑ Rappaport, Helen (1999). Joseph Stalin: A Biographical Companion . ABC-CLIO. ISBN   978-1-57607-084-0 .
• ↑ Беркович Артём. "Пермь и Екатеринбург: история соперничества" . Муниципальный музей истории Екатеринбурга. Archived from the original on 25 May 2013 . Retrieved 16 December 2009 .
• ↑ In the name of Victory. Sverdlovsk-Yekaterinburg during the Great Patriotic War of 1941–1945 . 2005 – via Ekaterinburg: Institute of History and Archeology of the Ural Branch of the Russian Academy of Sciences.
• ↑ "Свердловск – 1983 год" . 1723.ru . Retrieved 20 May 2018 .
• ↑ "Интервью – АПИ-Урал" . apiural.ru . Retrieved 15 May 2018 .
• ↑ "President Yeltsin speaks about Tsar Murder" . BBC News . 17 July 1998 . Retrieved 4 April 2012 .
• ↑ Matthew S. Meselson, et al., "The Sverdlovsk Anthrax Outbreak of 1979", Science 266:5188 (18 November 1994): 1202–1208.
• ↑ Martin McCauley, "Who's who in Russia since 1900", Routledge , 1997: p.133.
• ↑ Ровно 18 лет назад Свердловск снова стал Екатеринбургом . Официальный портал Екатеринбурга (in Russian). Archived from the original on 16 April 2013 . Retrieved 15 May 2018 .
• ↑ "О возвращении городу Свердловску его исторического названия Екатеринбург, Указ Президиума Верховного Совета РСФСР от 23 сентября 1991 года №1674-1" . docs.cntd.ru . Retrieved 15 May 2018 .
• ↑ (www.dw.com), Deutsche Welle. "First BRIC summit concludes | DW | 16 June 2009" . DW.COM . Retrieved 20 May 2018 .
• 1 2 FIFA.com. "2018 FIFA World Cup Russia" . fifa.com . Archived from the original on 12 April 2014 . Retrieved 23 May 2018 .
• ↑ "Russia moves to year-round winter time" . BBC News . 22 July 2014 . Retrieved 20 May 2018 .
• 1 2 3 Грязнов Олег Николаевич; Гуляев Александр Николаевич; Рубан Наталья Валентиновна (2015). "Факторы инженерно-геологических условий города Екатеринбурга" . Izvestiia Uralʹskogo Gorno-Geologicheskoĭ Akademii (журнал) (3) (Известия Уральского государственного горного университета   ed.). Екатеринбург: Федеральное государственное бюджетное образовательное учреждение высшего образования "Уральский государственный горный университет": 5–21. ISSN   2307-2091 .
• ↑ Погода и Климат – Климат Екатеринбург [ Weather and Climate – The Climate of Yekaterinburg ] (in Russian). Weather and Climate (Погода и климат) . Retrieved 8 November 2021 .
• ↑ "WMO Climate Normals for Sverdlovsk 1961–1990" . National Oceanic and Atmospheric Administration . Retrieved 29 October 2021 .
• ↑ Russian Federal State Statistics Service. Всероссийская перепись населения 2020 года. Том 1 [ 2020 All-Russian Population Census, vol. 1 ] (XLS) (in Russian). Federal State Statistics Service .
• ↑ "Национальный состав населения" (PDF) . Территориальный орган Федеральной службы государственной статистики по Свердловской области и Курганской области . Retrieved 7 June 2023 .
• ↑ "В Екатеринбурге заложили первый камень в основание соборной мечети – Уральская палата недвижимости" . upn.ru . Archived from the original on 10 October 2012 . Retrieved 5 October 2017 .
• ↑ "Четвертый канал" . channel4.ru . Archived from the original on 20 December 2010 . Retrieved 5 October 2017 .
• ↑ "Встреча Святейшего Патриарха Кирилла с общественностью Уральского федерального округа / Видеоматериалы / Патриархия.ru" . Патриархия.ru (in Russian) . Retrieved 18 October 2017 .
• ↑ "Устав Свердловской области (с изменениями на 7 декабря 2017 года), Устав Свердловской области от 23 декабря 2010 года №105-ОЗ, Закон Свердловской области от 23 декабря 2010 года №105-ОЗ" . docs.cntd.ru . Retrieved 2 May 2018 .
• 1 2 "Закон Свердловской области Губернатора Свердловской области № 141-ОЗ" . www.pravo.gov66.ru . Retrieved 12 March 2022 .
• 1 2 "Закон Свердловской области от 18.02.2021 № 9-ОЗ ∙ Официальное опубликование правовых актов ∙ Официальный интернет-портал правовой информации" . publication.pravo.gov.ru . Archived from the original on 12 March 2022 . Retrieved 12 March 2022 .
• 1 2 The population of the Russian Federation for municipalities as of 1 January 2019 Archived 16 October 2019 at the Wayback Machine (2 May 2019)
• ↑ "К 2023 году население Академического района вырастет до 120 тысяч человек" . Новый День (in Russian). 27 March 2019 . Retrieved 12 March 2022 .
• 1 2 "Chapter IV. Bodies and officials of local self-government of the municipality "city of Yekaterinburg" " . екатеринбург.рф . 25 July 2017. Archived from the original on 26 June 2016 . Retrieved 19 May 2018 .
• ↑ "Официальный интернет-портал правовой информации" . publication.pravo.gov.ru .
• 1 2 "Вы точно человек?" . КиберЛенинка . Retrieved 20 May 2018 .
• 1 2 "О внесении изменений в Устав муниципального образования "город Екатеринбург", Решение Екатеринбургской городской Думы Свердловской области от 12 октября 2010 года №62/29" . docs.cntd.ru .
• ↑ Article 42 of the Charter of Sverdlovsk Oblast
• ↑ "О ПРЕОБРАЗОВАНИИ И РЕОРГАНИЗАЦИИ АДМИНИСТРАЦИИ СВЕРДЛОВСКОЙ ОБЛАСТИ (с изменениями на: 06.02.1997), Постановление Правительства Свердловской области от 27 сентября 1995 года №13-П" . docs.cntd.ru .
• ↑ "Сведения о проводящихся выборах и референдумах" . sverdlovsk.vybory.izbirkom.ru . Archived from the original on 22 September 2013 . Retrieved 21 May 2018 .
• ↑ "Voting results for the Federal Electoral District – Election of Deputies of the State Duma of the Federal Assembly of the Russian Federation of the Seventh Convocation – September 18, 2016" . CEC. Archived from the original on 28 December 2016 . Retrieved 21 May 2018 .
• ↑ "Российские города отстают в развитии" . НИУ ВШЭ . 28 August 2014. Archived from the original on 5 February 2017 . Retrieved 7 July 2016 .
• ↑ "Urban world: Mapping the economic power of cities" . McKinsey Global Institute . March 2011. Archived from the original on 2 April 2024 . Retrieved 7 July 2016 .
• ↑ "Рейтинг столичных городов России от Фонда "Институт экономики города" | Институт экономики города" . urbaneconomics.ru . Retrieved 20 May 2018 .
• ↑ Economics of Russian cities and urban agglomeration , Institute for Urban Economics
• 1 2 Алексей Белоусов, Орнат Валентина. (13 October 2015). "Екатеринбург – глобальный город" . Мегаполис. Archived from the original on 27 August 2016 . Retrieved 7 July 2016 .
• ↑ Зубаревич Н.В. (2013). "Крупные города России: лидеры и аутсайдеры" (PDF) . Demoskop Weekly (журнал) (551–552) (Демоскоп Weekly   ed.). М.: НИУ ВШЭ: 1–17. ISSN   1726-2887 .
• ↑ "Екатеринбург вошел в топ-10 городов с самым высоким уровнем жизни" . JustMedia . 17 December 2014 . Retrieved 14 May 2018 .
• 1 2 3 "Results of social and economic development of the municipal formation "city of Yekaterinburg" in 2015" . 2016. p.   202 – via Ekaterinburg: Department of Economics of the Administration of the City of Yekaterinburg.
• ↑ "Итоги социально-экономического развития Екатеринбурга" . Archived from the original on 2 December 2020 . Retrieved 19 October 2022 .
• ↑ Дарья Воронина. (19 June 2013). "Главными проблемами Екатеринбурга назвали медицину, ЖКХ и дороги" . Российская газета . Retrieved 7 July 2016 .
• ↑ Юлия Позднякова. (22 April 2016). "Расходы бюджета Екатеринбурга за 2015 год составили почти 33 млрд рублей" . Коммерсантъ . Retrieved 7 July 2016 .
• ↑ Полина Путякова. (30 August 2016). "Меряемся бюджетами: Откуда города берут деньги и на что тратят" . zvzda.ru. Archived from the original on 2 September 2016 . Retrieved 7 July 2016 .
• 1 2 3 Kachanova E.A. Strategic Priorities for the formation of finance for municipalities in the context of reforming the budgetary system Archived 15 December 2017 at the Wayback Machine , – Moscow: Russian Academy of National Economy and State Service under the President of the Russian Federation, 2013. – 354 p.
• ↑ Vyacheslav, Kostyuk (12 December 2014). "His alien" . The Ural Worker . Archived from the original on 10 April 2018 . Retrieved 20 May 2018 .
• ↑ "Крупнейшие банки России по капиталу" . Журнал "Коммерсантъ Деньги" . 25 July 2016. p.   60 . Retrieved 20 May 2018 .
• ↑ "Крупнейшие производители ПО" .
• ↑ "О распределении обязанностей по контролю и надзору за соблюдением законодательства Российской Федерации организациями, осуществляющими профессиональную деятельность на рынке ценных бумаг, деятельность центрального депозитария, деятельность по проведению организованных торгов, клиринговую деятельность и деятельность центрального контрагента, репозитарную деятельность, а также деятельность саморегулируемых организаций в сфере финансового рынка, объединяющих профессиональных участников рынка ценных бумаг, и об отмене отдельных распорядительных актов Банка России, Приказ Банка России от 07 августа 2017 года №ОД-2228" . docs.cntd.ru .
• ↑ "Падающие пиксели и огромный шар: как может выглядеть "Екатеринбург-Сити" " . РБК Недвижимость . 13 September 2016 . Retrieved 20 May 2018 .
• ↑ Development results, 2016 , pg 76
• ↑ "ТОП-100 крупнейших предприятий Свердловской области Екатеринбург" . Деловой квартал. 11 October 2011 . Retrieved 14 June 2016 .
• ↑ "ИТОГИ социально-экономического развития муниципального образования «город Екатеринбург» в 2019 году" . Archived from the original on 29 November 2020 . Retrieved 19 October 2022 .
• ↑ Development results, 2016 , p. 127–128
• 1 2 Development results, 2016 , p. 129
• ↑ "Леруа Мерлен" . Archived from the original on 18 October 2021 . Retrieved 27 April 2020 .
• ↑ "Castorama – строительный гипермаркет: купить товары для дома, дачи и ремонта" . Castorama.ru . Retrieved 20 February 2022 .
• ↑ "Домострой" . Archived from the original on 30 July 2019 . Retrieved 27 April 2020 .
• ↑ "Максидом - интернет-магазин товаров для дома" . www.maxidom.ru . Retrieved 20 February 2022 .
• ↑ "ОБИ строительный гипермаркет: товары для дачи, сада, дома и ремонта: каталог ОБИ" . Obi.ru . Retrieved 20 February 2022 .
• ↑ "Строительный Двор – интернет-магазин стройматериалов, купить с доставкой строительные материалы в магазинах сети" . Sdvor.com . Archived from the original on 13 May 2020 . Retrieved 20 February 2022 .
• ↑ Development results, 2016 , pg 130
• ↑ Development results, 2016 , pg 131–132
• ↑ Development results, 2016 , pg 133–135
• ↑ "Топ-20 самых больших торговых центров РФ" . marketmedia.ru (in Russian) . Retrieved 11 December 2021 .
• ↑ "Сима-Ленд" . 20 October 2016.
• ↑ Вячеславовна, Логунцова Ирина (2015). "Специфика и перспективы Российской индустрии туризма на современном этапе" . Государственное управление. Электронный вестник (52): 259–278.
• ↑ Геннадьевич, Шеломенцев Андрей; Сергеевна, Головина Анна (2011). "Индустрия туризма региона в контексте принципов саморегулирования региональных социально-экономических систем" . Экономика региона (1): 166–170. ISSN   2072-6414 .
• ↑ Екатеринбург поднялся на третье место в топе российских городов по популярности среди иностранных туристов . URBC.RU – новости экономики (in Russian) . Retrieved 20 May 2018 .
• ↑ "Число посетивших Екатеринбург туристов выросло в 2015 году на 10%" . Retrieved 20 May 2018 .
• ↑ "Туристический мастер-класс" . expert.ru . Archived from the original on 13 September 2016 . Retrieved 20 May 2018 .
• ↑ Маренков Г.В. (2012). "Транспортная инфраструктура Свердловской области – связующее звено между Европой и Азией" (PDF) . Инфраструктура России (Том 1   ed.). М.: Центр стратегического партнёрства. pp.   254–260. Archived from the original (PDF) on 12 July 2018 . Retrieved 8 October 2017 .
• ↑ Мальцева Ю.; Волкова М.В. (2015). "Изучение возможности постройки современного экологического жилья в Свердловской области" (PDF) (сборник трудов IX заочной международной научно-практической конференции (Екатеринбург, 30–31 мая 2015 г.)) (Система управления экологической безопасностью   ed.). Екатеринбург: УрФУ. pp.   138–141.
• ↑ Ведомости (10 March 2015). "Автопарк России увеличился в 2014 году на 1 млн легковых машин" . Retrieved 8 October 2017 .
• ↑ "Вы точно человек?" . КиберЛенинка . Retrieved 8 October 2017 .
• 1 2 "ИТОГИ социально-экономического развития муниципального образования в 2015 году" . 2016. Archived from the original on 16 August 2021 . Retrieved 7 July 2022 .
• ↑ Цариков А.А.; Обухова Н.А.; Оглы Мирзоев Н.З. (2015). "Эволюция системы заторов на улично-дорожной сети города Екатеринбурга" (PDF) (журнал) (Эксплуатация автомобильного транспорта   ed.). Екатеринбург: Общероссийская общественная организация "Российская академия транспорта". pp.   74–86. ISSN   2311-164X . Archived from the original (PDF) on 12 July 2016 . Retrieved 8 October 2017 .
• ↑ Reports, Yekaterinburg News. "Sverdlovsk focusing on two road projects" . Archived from the original on 6 October 2017 . Retrieved 14 June 2017 .
• ↑ Крицкий В.П. (2009). "Дорожное хозяйство Екатеринбурга" (PDF) . Дороги России-2009. Информационно-аналитический каталог (Издание второе, подготовлено к IХ Международной выставке-форуму "Дороги России XXI века" и Дню работников дорожного хозяйства 3000 экз   ed.). Екатеринбург: Информационно-издательский холдинг "Реал-Медиа". pp.   204–205, 302. ISBN   978-5-98266-061-9 . Archived from the original (PDF) on 12 July 2018 . Retrieved 8 October 2017 .
• ↑ "Google Maps" . Google Maps . Retrieved 1 May 2018 .
• ↑ "Скандальный бывший МУП Мирошника лидер сферы общественного транспорта Екатеринбурга? По данным мэрии, именно трамваи перевезли больше всего горожан за 2015 год" . Ведомости-Урал. 18 March 2016. Archived from the original on 15 September 2016 . Retrieved 14 June 2016 .
• ↑ "БГД" . gks.ru . Archived from the original on 20 May 2016 . Retrieved 17 October 2017 .
• ↑ "Города Свердловской области" . gks.ru . Archived from the original on 10 July 2009 . Retrieved 8 October 2017 .
• ↑ "Основные технико-эксплуатационные характеристики метрополитенов за 2015 год" (PDF) . asmetro.ru. Archived from the original (PDF) on 8 August 2016 . Retrieved 14 June 2016 .
• ↑ Дмитрий Ольшванг. (18 March 2016). "Проблемы екатеринбургского метро: убытки, снижение пассажиропотока! Общественник Беззуб: "Если учитывать стоимость строительства станций, то цена билета на метро должна быть 144 рубля"..." Ведомости-Урал. Archived from the original on 15 September 2016 . Retrieved 14 June 2016 .
• ↑ "Шины для трамваев, бензин для поездов. Документы: на что транспортные МУПы Екатеринбурга тратят деньги" . uralpolit.ru . Retrieved 13 March 2014 .
• ↑ "Города Свердловской области" . gks.ru . Archived from the original on 30 June 2013 . Retrieved 18 October 2017 .
• ↑ "Строительство трамвайной линии Екатеринбург – Верхняя Пышма начнут в 2016 году" . Портал 66.ru. 22 July 2015 . Retrieved 22 July 2015 .
• ↑ "Официальный портал Екатеринбурга" . Официальный портал Екатеринбурга . Retrieved 18 October 2017 .
• 1 2 "Города Свердловской области" . gks.ru . Archived from the original on 10 July 2009 . Retrieved 18 October 2017 .
• ↑ Автобусный парк Екатеринбурга утепляют к зиме . УралИнформБюро (in Russian) . Retrieved 18 October 2017 .
• ↑ "Более 5,4 миллионов пассажиров обслужил аэропорт Кольцово в 2017 году   (АвиаПорт)" . АвиаПорт.Ru (in Russian) . Retrieved 1 May 2018 .
• ↑ "БГД" . gks.ru . Archived from the original on 15 June 2009 . Retrieved 25 May 2018 .
• 1 2 According to the city directory Dubl.
• ↑ Уральский научно-исследовательский институт фтизиопульмонологии – филиал ФГБУ "НМИЦ ФПИ" Минздрава России . urniif.ru (in Russian) . Retrieved 25 May 2018 .
• ↑ "Официальный сайт ГБУ СО "Уральский научно-исследовательский институт дерматовенерологии и иммунопатологии" " . urniidvi.ru . Retrieved 25 May 2018 .
• ↑ Екатеринбургский центр МНТК "Микрохирургия глаза" . eyeclinic.ru (in Russian) . Retrieved 25 May 2018 .
• ↑ Открытие второго центра МРТ-диагностики в городе Екатеринбурге! . ekaterinburg.ldc.ru (in Russian) . Retrieved 25 May 2018 .
• 1 2 М.м, Рогалёва (2014). "Екатеринбург как современный мегаполис" . Человек в мире культуры (4): 14–17. ISSN   2227-9857 .
• ↑ Report of the head of the Yekaterinburg administration, 2016 Archived 5 February 2017 at the Wayback Machine , p. 14.
• ↑ Report of the head of the Yekaterinburg administration, 2016 Archived 5 February 2017 at the Wayback Machine , p. 13, 15.
• ↑ Лучшие школы России-2015 . РИА Новости (in Russian). 12 October 2015 . Retrieved 22 May 2018 .
• ↑ "Общие сведения об университете – ФГБОУ ВО "Уральский государственный горный университет" " . about.ursmu.ru . Archived from the original on 7 July 2016 . Retrieved 22 May 2018 .
• ↑ The second business rating of higher education Archived 29 September 2018 at the Wayback Machine – Federal Portal Russian Education, 22 May 2018
• ↑ Formation of the state elite 2008 Archived 5 February 2017 at the Wayback Machine – Federal Portal Russian Education, 22 May 2018
• ↑ "Российская академия наук намерена готовить кадры самостоятельно | Новости образования | Обучение Екатеринбург" . uchim66.ru . Archived from the original on 4 March 2016 . Retrieved 22 May 2018 .
• ↑ "УрФУ перестраивается в школы" . Коммерсантъ (Екатеринбург) . 22 April 2016 . Retrieved 22 May 2018 .
• ↑ "По количеству бюджетных мест мы уже обошли МГУ" . 7 April 2021.
• ↑ "Ural Federal University – UrFU" .
• ↑ Case study: Ural Federal University as a basic university of industry in the region Archived 1 April 2019 at the Wayback Machine . – Ekaterinburg: Ural Federal University, 2016. – p. 2, 9–10.
• ↑ "Гильдия издателей периодической печати" . 18 September 2011. Archived from the original on 18 September 2011 . Retrieved 26 February 2022 .
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• ↑ Официальный сайт "Вести Урал" – Официальный сайт "Вести Урал" . Официальный сайт "Вести Урал" (in Russian). Archived from the original on 16 July 2012 . Retrieved 22 May 2018 .
• ↑ Вальханская, Наталья (24 March 2018). Взрыв и обрушение: снос телебашни в Екатеринбурге на видео очевидцев . Телеканал "Звезда" (in Russian) . Retrieved 22 May 2018 .
• ↑ "Тёмная башня" . 1723.ru . Retrieved 22 May 2018 .
• ↑ "Uralnets" . uralnets.ru . Retrieved 26 February 2022 .
• ↑ Fletcher, Martin. "Yekaterinburg signs cooperative agreement with Vimpelcom under Beeline brand" Archived 22 July 2013 at archive.today , Yekateringburg News , 19 July 2013. (Retrieved 22 July 2013).
• ↑ "WiseCms – troubles..." culture.ekburg.ru . Archived from the original on 11 July 2012 . Retrieved 24 May 2018 .
• ↑ "WiseCms – troubles..." Culture.ekburg.ru . Archived from the original on 19 January 2011 . Retrieved 24 May 2018 .
• ↑ "Триумф России на Всемирной выставке в Париже 1900 года – Новости РуАН" . новости-россии.ru-an.info . Retrieved 20 February 2022 .
• ↑ Lykova TR   Cultural and historical centres of the Sverdlovsk region Archived 11 October 2016 at the Wayback Machine   // method. instructions for studying the course "Cultural and Historical Centres of the Urals" for full-time or part-time students, direction 100400 – Tourism. – Ekaterinburg: UGLTU, 2014. – P. 15-16 .
• ↑ "Главная страница - АПИ-Урал" . www.apiural.ru . Retrieved 26 February 2022 .
• ↑ "Архитектура и планировка социалистического Свердловска. Часть 2" . 1723.ru . Retrieved 24 May 2018 .
• ↑ Вейн, Инна (10 November 2020). "Уральские актеры и режиссеры привезли домой сразу четыре "Золотые маски" " . Ekb.dk.ru (in Russian) . Retrieved 15 August 2021 .
• ↑ Fletcher, Martin. "Yekaterinburg to showcase city’s cultural achievements during Year of Culture" Archived 13 February 2014 at archive.today . Yekaterinburg News . 13 February 2014. (Retrieved 13 Feb 2014).
• ↑ Pozdnyakova, Julia (27 May 2016). "Sverdlovsk Oblast was in the picture" . Kommersant . Retrieved 24 May 2018 .
• ↑ "Интервью - АПИ-Урал" . www.apiural.ru . Retrieved 26 February 2022 .
• ↑ "Премией "Шаривари" отметили лучших деятелей циркового искусства – В МИРЕ ЦИРКА И ЭСТРАДЫ" . ruscircus.ru . Retrieved 25 May 2018 .
• ↑ "Ельцин Центр признали «лучшим европейским музеем 2017 года»" . The Village (in Russian) . Retrieved 15 August 2021 .
• ↑ Самые популярные достопримечательности Екатеринбурга соединит красная линия на тротуаре . Interfax-Russia.ru (in Russian). 17 June 2011 . Retrieved 25 May 2018 .
• 1 2 Yekaterinburg Encyclopedia (PDF) . Yekaterinburg: "Akademkniga". 2002. p.   30. ISBN   5-93472-068-6 – via PDF.
• ↑ Yekaterinburg Encyclopedia (PDF) . Yekaterinburg: "Akademkniga". 2002. pp.   30–31. ISBN   5-93472-068-6 – via PDF.
• ↑ Yekaterinburg Encyclopedia (PDF) . Yekaterinburg: "Akademkniga". 2002. p.   31. ISBN   5-93472-068-6 – via PDF.
• 1 2 3 Shvets, A. V. (2016). "Domestic architecture of the late XX – early XXI century" (PDF) . New Ideas of the New Century: Scientific. Compilation . 2 . Khabarovsk: Pacific State University: 355–362. Archived from the original (PDF) on 4 November 2016 . Retrieved 8 June 2018 – via PDF.
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• 1 2 "The announcement ceremony of the host cities of the 2018 World Cup united the whole of Russia" . ru.fifa.com . Archived from the original on 3 September 2014 . Retrieved 23 May 2018 .
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• ↑ sport, Guardian (4 October 2017). "Outer space: the Russia World Cup stadium with a novel seating extension" . the Guardian . Retrieved 23 May 2018 .
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• ↑ FIFA.com. "2018 FIFA World Cup Russia - News - FIFA Fan Fest venues announced for 2018 FIFA World Cup Russia" . fifa.com . Retrieved 23 May 2018 .
• ↑ Azmukhanov, Alexander (3 May 2018). "The three most expensive projects of the region for the World Cup" . Oblastnaya Gazeta . Retrieved 22 May 2018 .
• ↑ "Official website of the U.S. Consulate General in Yekaterinburg" . Archived from the original on 8 April 2012 . Retrieved 19 April 2012 .
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• ↑ "Official website of the German Consulate General in Yekaterinburg" . Retrieved 19 April 2012 .
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• ↑ "First summit for emerging giants" . BBC News . 16 June 2009 . Retrieved 16 June 2009 .
• ↑ Hamilton, Louis (18 June 2013). "Yekaterinburg presents city's bid for 2020 World Expo" . Yekaterinburg News. Archived from the original on 27 November 2013 . Retrieved 20 June 2013 .
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• ↑ КИРЯГИН, Кирилл (22 July 2015). "ИННОПРОМ – в пятёрке крупнейших промышленных выставок мира" . ural.aif.ru (in Russian) . Retrieved 12 December 2021 .
• ↑ "Побратимы и тезки Екатеринбурга" . ekb-room.ru (in Russian). The Ekb Room. 20 October 2014. Archived from the original on 18 November 2018 . Retrieved 22 December 2020 .
• ↑ "Museum Vladimir Mulyavin in Belarusian State Philharmonic" . Retrieved 22 April 2022 .
• Екатеринбургская городская Дума.   Решение   №8/1   от   30 июня 2005 г. «О принятии Устава муниципального образования "Город Екатеринбург"», в ред. Решения №1/27 от   27 января 2015 г.   «О внесении изменений в Устав муниципального образования "Город Екатеринбург"». Вступил в силу   со дня официального опубликования. Опубликован: "Вестник Екатеринбургской городской Думы", №95, 15 июля 2005 г. (Yekaterinburg City Duma.   Decision   # 8/1   of   June   30, 2005 On the Adoption of the Charter of the Municipal Formation of the "City of Yekaterinburg" , as amended by the Decision   # 1/27 of   January   27, 2015 On Amending the Charter of the Municipal Formation of the "City of Yekaterinburg" . Effective as of   the day of the official publication.).
• Областная Дума Законодательного Собрания Свердловской области.   Областной закон   №30-ОЗ   от   20 мая 1997 г. «Об административно-территориальном устройстве Свердловской области», в ред. Закона №32-ОЗ от   25 апреля 2012 г.   «О внесении изменений в Областной закон "Об административно-территориальном устройстве Свердловской области"». Вступил в силу   со дня официального опубликования за исключением отдельных положений, вступающих в силу в иные сроки. Опубликован: "Областная газета", №81, 3 июня 1997 г. (Oblast Duma of the Legislative Assembly of Sverdlovsk Oblast.   Oblast Law   # 30-OZ   of   May   20, 1997 On the Administrative-Territorial Structure of Sverdlovsk Oblast , as amended by the Law   # 32-OZ of   April   25, 2012 On Amending the Oblast Law "On the Administrative-Territorial Structure of Sverdlovsk Oblast" . Effective as of   the day of the official publication with the exception of several clauses which take effect on a different date.).
• Областная Дума Законодательного Собрания Свердловской области.   Закон   №85-ОЗ   от   12 июля 2007 г. «О границах муниципальных образований, расположенных на территории Свердловской области», в ред. Закона №107-ОЗ от   29 октября 2013 г.   «Об упразднении отдельных населённых пунктов, расположенных на территории города Ивделя, и о внесении изменений в Приложение   39 к Закону Свердловской области "О границах муниципальных образований, расположенных на территории Свердловской области"». Вступил в силу   через 10   дней после официального опубликования. Опубликован: "Областная газета", №232–249, 17 июля 2007 г. (Oblast Duma of the Legislative Assembly of Sverdlovsk Oblast.   Law   # 85-OZ   of   July   12, 2007 On the Borders of the Municipal Formations on the Territory of Sverdlovsk Oblast , as amended by the Law   # 107-OZ of   October   29, 2013 On Abolishing Several Inhabited Localities on the Territory of the Town of Ivdul and on Amending the Law of Sverdlovsk Oblast "On the Borders of the Municipal Formations on the Territory of Sverdlovsk Oblast" . Effective as of   the day which is 10   days after the official publication.).
• Official website of Yekaterinburg (in Russian)