Russia's healthcare system was already working at full capacity before coronavirus. We spoke to one of the people organising Russian healthcare workers on workloads, optimisation and wages.

After years of overwork and poor wages, Russia's healthcare workers are increasingly organising in support of decent pay and conditions.

But what challenges will Russia's health workers face with the spread of COVID-19? And what kind of toll will the crisis take on a system known for overwork, staff cuts and shortages?

We spoke to Andrey Konoval, co-chairperson of the independent Action healthcare worker union, about how coronavirus could reveal the depth of the challenges facing Russia's healthcare system.

Q: How has the work of Russian medical staff changed as a result of the government's increased readiness measures? And if so, then why, given that the numbers of people infected are minimal so far?

The scale of infection in Russia isn't so large yet, so we're yet to see a particular effect on the majority of staff.

But there are some initial causes of alarm. This comes mostly from ambulance crews, whose workers in recent years have been particularly active in joining our trade union. Their workload hasn't increased dramatically, but if we can't restrain the epidemic with quarantine measures, then there will be serious problems in my view.

The issue is that Russia's ambulance crews, much like several other areas of the healthcare system, have been working at their limit in recent years. In the majority of regions there's a clear lack of personnel, which means both a reduced number of crews, and the number of staff in them.

According to one Russian Health Ministry directive, it's recommended to have one equipped general ambulance crew per 10,000 people, and a specialised crew - for example, psychiatric or intensive care - per 100,000. None of this is observed in practice. I won't say anything about specialised crews: several cities either don't have them at all (for example, in Oryol there's not a single emergency ambulance crew), or, like in Izhevsk, there's one emergency crew for 700,000 people. According to a national directive, in Ryazan, there should be 52 general ambulance crews for 525,000 people. Officially there's 43 crews, but in reality, there's 35, and sometimes less.

This means, of course, a huge increase in workload for healthcare staff, and often they don't arrive in the 20-minute window they're supposed to. When there's a peak of infection or injury, an ambulance crew can be fielding 18-25 calls in a 24-hour period, and sometimes up to 30. This is up to twice more than what used to be considered the norm. Staff are completely worn out. And it's impossible to solve the issue by putting people on overtime, because most medical staff are already working several jobs at once in order to compensate for their humiliatingly small wages - often they're working an extra half-workload or double. If we see an increased rate of COVID-19 infection, and the appropriate safety measures are passed, then their workload is going to be colossal.

We've already seen cases where ambulance crews who come into contact with people with coronavirus - and who don't have the right protection equipment - have to go into two-week quarantine. Which means even less crews. Ambulance workers are supposed to completely disinfect their vehicles after transporting someone suspected of coronavirus, but many of their relay stations aren't equipped with areas to clean vehicles.

With COVID-19, healthcare staff should be medically examined twice a day. How are they supposed to do this if they don't have any time to rest or eat?

Q: Which of the Health Ministry's recommended measures are ambulance workers supposed to carry out?

Russia's Health Ministry and Consumer Rights Service have developed measures against coronavirus, but not all of them are carried out in the regions.

For example, when ambulance crews are called out to a patient suspected of coronavirus, they should have - aside from protective clothing - respiratory equipment or single-use masks, which should be changed after every patient. In the majority of cases, ambulance staff don't have this equipment.

For example, in Ryazan, ambulance workers received two practically self-made masks each - and were told that's fine, and that they should wash and iron their masks themselves. How can they do that during a shift? After the trade union kicked up a fuss, ambulance workers were issued single-use masks - and were photographed with them, as if to show that everything was now fine. But we're still talking about three masks per staff member for dozens of call-outs a day. Now they've bought some more cheesecloth, it seems they'll be sewing more together.

Detail: Russia's Action (Deistvie) trade union was founded in 2012 by healthcare workers from Moscow and Izhevsk, and a 2013 work-to-rule action in the latter brought its first victory. Medics in the city organised a slowdown by performing their roles according to official guidelines, in order to show how their system was running on excessive) overtime. Today, the union has 60 branches across 40 of Russia's 85 regions, and is part of a growing independent trade union movement in the country.

In some places, staff members are being trained - elsewhere, they're not. Managers don't pick out specific crews for treating potential coronavirus infections - they just send the crews who are free.

The situation is tense. It's not just regular people who could be panicked, it's healthcare staff themselves - they see that they haven't yet got the right protection equipment. I don't want to say that the authorities aren't doing anything in this area. They are, but they're coming up against a serious personnel shortage. This is a serious problem. After all, the healthcare system was already working at full capacity before coronavirus.

Q: How about doctors who are retirement-age, they are already in the at-risk group for the new coronavirus? For example, in Altai region last year, the head of the local health ministry stated that 27% of healthcare staff are retirement-age. Are they being kept away from work with people who are potentially infected?

So far I haven't heard that this issue has been brought up specifically. Public officials are already dealing with personnel shortages. I suspect that these staff will just be given the general safety equipment - masks, uniforms.

Q: How ready are hospitals for a possible epidemic given the healthcare reforms in recent years?

As part of the healthcare optimisation, hospital provision has been cut - bed numbers have dropped, services have closed, as well as whole hospitals, including ones with infection units.

The idea was to increase the level of out-patient treatment, just like in the west. It's considerably less expensive. But in practice, in-patient services were cut, and out-patient services were not increased. It's not for nothing that the president called the optimisation of primary care a "failure" last year. This means out-patient services too. And it's why we have a situation where clinics have problems, and hospitals don't have enough beds.

Imagine what will happen if we get a sudden rise of new coronavirus patients when our infection wards are already overflowing every autumn and winter. Often, kids can't be hospitalised because of a lack of beds in infection wards - in cases where it makes sense to bring them in. And parents themselves at time sprefer not to hospitalise their children because they don't want to be in an over-subscribed ward. In Udmurtiya, for example, four years ago the number of children and adult beds in infection wards was halved, according to the per-patient financing principle.

At the Sechenovskaya Central District Hospital in Nizhgorod region, I've been told that the infection ward is set up for six patients, but since January there have been around 12-15 patients constantly with different infections. How is that possible? Two per bay, in extra beds, although a bay is set up for one person. Even without coronavirus, the situation was already tense.

Q: Can infection wards be set up quickly?

Probably it's possible, but you need serious finances for it, and medical institutions have been living with a sharp financial deficit for years. Our healthcare system is not financed according to an estimated budget whereby, for example, a hospital has 80 doctors' wages and a separate budget line allocates funds for all these ages, to make sure there are doctors. In state medical institutions we have cost accounting or self-financing - allegedly in order to raise competition.

All funds aside from infrastructure repair should go through the regional programmes of Russia's obligatory health insurance system (OMS). Even if a region wants to invest extra funds in a hospital, for example by increasing the number of beds in a ward, then the funds have to come via the OMS system. The regional OMS programme states the number of services for each treatment centre, as well as tariffs for those services. All of this should be budgeted properly, but in reality tariffs and the number of services are reduced to save money, and services are often not paid for due to fines levied by the insurance companies. (This is mostly due to medical documents that have not been properly filled out.) As a result, some of the reserved funds stay in the central fund. And medical institutions acquire serious debts to it. For example, state medical centres in the Kuzbass owed 1.7 billion roubles (£18.2 million) in 2019.

Q: Which staff are going to be lacking if the coronavirus spreads further in Russia?

There's already a personnel shortage. If the situation with coronavirus gets worse, then the weak points in the system are going to be revealed. I don't think that our healthcare system can't cope [with an outbreak of COVID-19]. It can cope, but due to the accumulation of unresolved problems we'll see a lot of defeats on this front.

Doctors are already working one-and-a-half or two jobs on average. And these numbers don't reflect people's entire workloads, but only additional work - as agreed by contract. Because there's also additional workloads every day - for example, mixing roles or expanding an area that has to be worked. That's when a district therapist covers not one, but two or three districts, or when an ambulance crew has to cover an area of 20,000 people, not 10,000.

The situation for junior personnel is becoming catastrophic. As a category of staff, unlicensed assistive personnel (such as nursing assistants), junior nurses have been subject to "professional genocide".

Over the past five to six years, the number of jobs in this area has dropped from 700,000 to somewhere around 300,000 - and perhaps less. And the jobs are still being actively cut. Junior medical staff are being categorised as cleaners, but still have to carry out the duties they had before. But the jobs that a cleaner and nursing assistant have to do in a hospital are fundamentally different things.

The work of junior staff in hospitals requires specific professional skills and psychological preparation. This is difficult and not particularly appealing work, and it should be well paid.

Q: But surely cleaners aren't allowed to care for patients?

To keep in line with professional standards - under which cleaners don't have the right to carry out sanitary and disease control measures in wards with patients - people working as cleaners are allocated 0.75 cleaner contract, and 0.25 under a nursing assistant contract. It's the same for junior nurses: hospital cleaners don't have the right, for example, to give injections or turn patients, so they are hired at a 0.75 cleaner contract, and a 0.25 junior nurse contract.

Q: Why are nursing assistants and nurses being forced to work as cleaners?

Junior personnel are being cut in order to raise the statistics on wages for junior and mid-level healthcare staff - they should meet the average wages for the region they're working in. This is a requirement of one of the 2012 "May Decrees" issued by the president.

Detail: The "May decrees", initially signed on the eve of Putin's third inauguration in 2012 and recently updated, are designed to modernise Russia's healthcare and education sectors. At the same time, these decrees linked pay rises for public sector personnel across the country to targets on pay and performance - which ended in significantly increasing workloads for healthcare staff.

Q: In the Moscow hospital where coronavirus patients are being treated, the BBC has reported that doctors' wages are 140,000 roubles (£1,500), including additional payments of 70,000 roubles (£750) for doctors and 50,000 (£540) for nurses. Has your trade union received information about similar additional payments outside of Moscow?

It's possible in Moscow that doctors fighting coronavirus are getting significant additional payments. Medical workers in the capital have pretty high average wages, although that's also due to their overtime. But the rest of Russia is a different story. It was announced nationally that those medical staff who are involved in the fight with coronavirus will receive additional payments, but how it will happen in practice, it's hard to say. Our union doesn't have any information about additional payments in the region yet.

Q: Which are the most problematic regions in Russia in terms of medical workers' rights? What kind of complaints do you receive most often?

The most frequent complaints that come in deal with low wages, loss of stimulation payments without reason. People often write that medical staff don't get their overtime pay properly, or that their workload has been increased.

One of the fundamental problems with healthcare workers' wages is the low basic wage. The basic wage is often 50% of their overall wage, so when someone loses their stimulation or compensation payments, then they can't make their wages last at all for a normal life.

The most problematic region is, in my view, the North Caucasus. We get a lot of complaints from there, although we have hardly any members there. You can lose your stimulation payments very easily there, without reason. This often happens in medical centres outside the cities and towns. My general impression from the complaints we've had is that the Russian Labour Code doesn't even exist there. We can see this in the official statistics on average wages for doctors. That said, several regions in central Russia have also stood out there - Bryansk, Oryol regions, for example. If you take a wider view, then the situation is more or less the same everywhere if you exclude Moscow, Petersburg and several other richer regions.

The risk of a coronavirus outbreak is a challenge for Russia's healthcare system. It will expose all the systematic problems which preivously the authorities tried to ignore.