Social health problems and ways to solve them. Social health problems
Currently, in the sphere of activity of the Ministry of Health and Social Development of Russia, various information systems and databases are used, containing significant volumes of information on health issues, social development, labor, employment, the collection of which is carried out by organizations subordinate to the Ministry of Health and Social Development of Russia. Considerable experience has been accumulated in the implementation and support of these systems. The presence of differences in information systems is due to the difference in approaches to their creation and maintenance. Previously created information systems are predominantly narrowly focused, focused on providing specific functions and tasks. Their development during operation gave not only tangible results, but also gave rise to serious problems. Built on the bottom-up principle, by continuously building up and linking old and new technologies, existing information systems are more likely a complex of automated workstations than a single information environment. Organizational and technological solutions implemented by software are rigidly tied to the organizational structure of the Ministry and subordinate organizations that existed at the time the systems were created.
In particular, the following issues should be noted:
Existing information systems partially overlap each other in their functions, are weakly linked structurally, support different data formats and cannot be integrated into one system without significant rework;
There is no unified infrastructure for collecting, storing, processing, transferring and using information in the field of health care, social development, labor, employment;
Existing information systems are not designed to work in a single information space, and the data transmission technologies used are not capable of ensuring data updating in the required time scale;
There are no unified information resources containing interconnected information about objects and subjects of accounting in the spheres of health care, social development, labor, employment;
There is no possibility of correlating, comparing and analyzing data from various information systems to obtain complete, reliable and up-to-date information on the state of the health sector, social development, labor, employment;
There is a high level of duplication of information due to the inaccessibility of data from different information systems for each other;
A number of systems have become obsolete morally and physically, both in terms of software and hardware;
There is no unified legal, organizational and methodological basis for the functioning and use of information systems.
The elimination of these shortcomings cannot be carried out by simply adjusting the existing information systems and ensuring their interaction with each other. Over the past year, the activities of the Ministry of Health and Social Development have become so clearly contrasted with the tasks set before them that it has become simply impossible not to pay any attention to it.
The adoption of the Law “On Circulation of Medicines” and the Law “On Compulsory Health Insurance in the Russian Federation” without taking into account the comments and proposed amendments of the professional community led to an increase in tension in society and confrontation between doctors, the expert and scientific community and the Ministry. And these are not isolated examples. Complete disregard of the opinion of the professional community, refusal to provide information, from participation in discussions, round tables observed in all spheres of competence of the Ministry without exception. At the same time, the country is witnessing constant corruption scandals related to the activities of the Ministry; in all areas of its work, there is a constant pushing of its narrow departmental interests, hiding its plans and programs from society, and non-transparency of decision-making procedures.
In this regard, it is surprising and regrettable that the bill "On the basics of protecting the health of citizens in Russian Federation”, Which was supposed to become the basic law arising from the Concept, was submitted to the State Duma without wide discussion for its early adoption. There are numerous comments and suggestions to this document that have not been reflected in this draft law. The most important aspiration of Russians - the guarantee of free medical care - is vague and vague in the law. Moreover, the regulation paid services it is prescribed in such a way that it allows you to practically uncontrollably collect money from the population, even for life-saving medicines and procedures. The draft law contradicts a number of articles of the Constitution of the Russian Federation, many international conventions, is not supported by the opinion of experts, historical, sociological and economic information. The bill does not take into account the context of the socio-economic development of the country as a whole. In particular, a steady increase in social inequality between individual social groups of the population and regions, depopulation processes, negative trends in family development, the situation in the sphere of labor and employment.
There is also ineffective management of the health care system in the Ministry. It manifests itself in the absence of strategic planning and responsibility of managers at all levels for achieving results. Firstly, in the Russian Federation there is no system for assessing the performance of health managers at all levels (including annual reports) according to the indicators adopted in developed countries ah, for example, in terms of quality and safety of medical care, efficiency of activities, etc. The available reports of the Ministry of Regional Development of the Russian Federation on the effectiveness of the activities of executive authorities (in terms of health care) do not reflect the real picture in the regions, since the comparison is based on outdated (Soviet times) and non-differentiated standards, for example, without dividing beds by intensity level and doctors into primary contact doctors and specialists. Secondly, ineffective management manifests itself in the irrational distribution of public funds. Thus, the emphasis in government programs is placed on investment costs (construction and purchase of expensive equipment) that are poorly controlled and have high risks of corruption payments (construction and purchase of expensive equipment) instead of developing prevention and human resources. Thirdly, in a number of cases there is a low scientific validity of the decisions made in healthcare and the opinion of the professional medical community is not used enough. For example, the Commission is responsible for approving the procedures and standards of medical care, which includes practically only one officials, except for one - the head of an academic clinical institution. Fourth, underutilized cost-effective management tools, such as quality competition when purchasing health care from providers medical services, drawing up ratings of health care facilities, applying economic incentives to achieve planned results. All this leads to ineffective spending of scarce public resources.
Another problem is the shortage and imbalances in the structure of medical personnel. No doctors - no medical care available. The provision of doctors per 1000 population, excluding sanitary-epidemiological personnel and dentists, was 4.4 in the Russian Federation, which is 1.4 times higher than the average in OECD countries, where it is 3.1 doctors per 1000 population. However, in the Russian Federation, the morbidity and mortality rate of the population is higher than in the OECD countries, by at least 30-40%, therefore, the assertions of some experts about the surplus of doctors in the Russian Federation are unfounded. Attention should also be paid to the low level of remuneration of the teaching staff of universities, which, of course, does not stimulate an increase in the level of education of students. Moreover, in the Russian Federation there is a suboptimal structure of medical personnel in comparison with developed countries: the provision of primary care physicians is 1.7 times lower; the ratio of doctors and nurses in the Russian Federation is 1: 2.4, while in developed countries it is on average 1: 3. It is also necessary to note the suboptimal distribution of medical personnel: in rural areas, the provision of doctors and paramedical personnel is significantly lower than the average for the Russian Federation, by 4 and 2 times, respectively.
Hence the next problem is the insufficient qualification of medical personnel and, as a consequence, the unsatisfactory quality of medical care. No doctor is bad, but no qualified doctor is even worse. Insufficient qualifications of medical personnel are manifested in unsatisfactory indicators of the quality of medical care in comparison with developed countries. For example, the survival rate of patients with breast cancer, the rate of in-hospital mortality, mortality of patients with bronchial asthma and other indicators are 2-3 times higher than in OECD countries. The problems facing the health care sector are primarily intended to be solved by the state health care management system, however, its state and activity at the present time is not at the proper level. It is necessary to develop a health assessment system through a gradual increase in funding for activities aimed at reducing the consumption of tobacco and alcohol, for the provision of medical and preventive care to the population based on the developed methods and standards. through supervision in the field of consumer protection, as well as ensuring a safe and comfortable working environment. It is also necessary to develop modern approaches and provide conditions for training specialists, improve curricula, and develop the infrastructure of scientific and educational institutions.
The most important problem in the Ministry is a poorly functioning structure. The legislation governing the healthcare sector does not form the organizational unity of all links of the system. As a result, the ongoing reforms, affecting the development of certain areas, do not ensure the consistency, dynamism and integrity of the reform process.
The success of reforms in health care is determined by a single scientifically grounded strategy containing ways to overcome the crisis in the entire social sphere. It is obvious that the modern social policy in health care, built on an objective knowledge of the factors forming a healthy population and the state of the country's economy, requires a detailed study of legal regulation in the industry. For this, first of all, it is necessary to improve the legislation regulating legal relations in health care and ensuring the organizational unity of the system as a whole, as well as establishing the responsibility of the constituent entities of the Russian Federation at all levels for the state of health of the population. For the functioning of the unified health care system of the Russian Federation, it is necessary to develop a Federal Law on the coordination of health care issues with the establishment of specific measures for its implementation, including administrative and criminal sanctions. The norms of this law should be concretized in the laws of the constituent entities of the Federation, in addition, both in the federal law and in regulations constituent entities of the Russian Federation, a boundary should be established for the implementation of their powers by municipalities.
The protection of public health is one of the most important tasks that must be addressed by the government. In recent years, the healthcare system has experienced both ups and downs. This is due primarily to economic crises and constantly growing inflation. The state of the health care system is assessed by factors such as the number and level of medical institutions, the percentage of deaths from diseases and the availability of innovations. For an objective assessment of the situation in the modern health care system, we will pay attention to these aspects in this article.
Reducing the number of medical institutions
Many Russian experts agreed that in the near future the number of medical institutions in the country will continue to decline. In their opinion, by 2021 the number of hospitals in the country may decrease to the level of 1913. This is not a mere opinion, but a factual conclusion.
According to official statistics (CEPR data), in the period from 2000 to 2015, the number of state medical institutions in the Russian Federation decreased by 2 times (from 10,700 to 5,400). In its report, a group of analysts expressed the opinion that if the government continues to close municipal hospitals at the same pace (today this figure is 353 per year), then by 2022 their number will reach 3,000 institutions, which is comparable to 1913.
The number of rural medical institutions is declining at an incredible rate: out of 4.5 thousand, only 400 hospitals remain in the whole of Russia. Thus, the availability of medical care for rural and rural residents has been reduced to almost zero, for 40-60 km not everyone will go to the paramedic, and only in an emergency, since there is nowhere to wait for an ambulance.
Also for this period the number of hospital beds in hospitals decreased to 1,200 thousand (a decrease of 27.5%). The worst of all is in rural areas - here the decline has reached a critical level - 40%. The data are confirmed by the Health Foundation and personally by its director E. Gavrilov. He voiced a sad fact: in the last 3.5 years alone, the number of hospital beds has decreased by 100,000.
However, the reduction in hospital beds does not affect the availability and quality of medical care in the country. Experts insist that the key indicator is the number of hospitalizations. Oddly enough, it is growing. So, in 2016, almost 100 thousand more people were hospitalized in Moscow than in 2015. According to experts, each hospital bed should be loaded by at least 85%. If this figure is lower, you should get rid of it in order to save money. Such a policy seems rational, because resource optimization is the key to prosperity.
There is one more nuance. When an epidemic of any disease (even a banal flu) breaks out in a particular region, the number of hospital beds is sometimes not enough. Hence the conclusion - Russia has approached the critical level of the number of hospital beds per capita. If the dynamics continue, or an epidemic breaks out across the country, requiring hospitalization, then citizens will face a shortage of medical care. It will be physically impossible to quickly fill the gap in state medical institutions.
Reduced mortality from disease
According to the Russian Center for Research, in 2016 the number of deaths from major diseases decreased by 1.2% compared to 2015. This confirms the fact that the level of medical care in Russia, despite all the problems, is at a high level. In 2016, mortality from the following groups of diseases decreased:
- Respiratory organs - by 7.9%
- Digestive organs - by 3.4%.
- Circulatory systems - by 2.6%.
- From malignant neoplasms - by 0.6%
- From external causes - by 6.5%.
An overabundance of managers in the health care system
The Chicago City Department of Health (population 9 million) employs only 8 people. In the same organization in Moscow (population 15 million) - about 2000 people. A clear numerical superiority of the administrative apparatus is observed in the Russian capital, but does this translate into the level of medicine? No. There is a shortage of equipment and free medicines in the country.
average salary Ministry of Health officials is 100 thousand rubles. If the staff is reduced to 100 people (which, by the way, is still 12.5 times more than in the city of skyscrapers), then the amount of 1900 x 100,000 = 190,000,000 rubles will be saved monthly. With this money, you can buy 12 MRI machines (if we talk about a simple Hitachi Airis Elite 0.3T model worth 16 million rubles).
What else is fraught with the excess of the management apparatus in the health care system? First, bureaucratic problems. Doctors spend the lion's share of their time compiling the various reports required by the top management. This time they could spend on helping the sick, instead they have to constantly report to their management.
The government does not spare money for the salaries of the management, but the state budget does not have enough funds to provide the population with free medicine. So, since 2014, there has been a decline in financing of the health care system:
- 2014 - the budget of the health care system amounted to 462 billion rubles;
- 2015 - 406 billion rubles;
- 2016 - 419 billion rubles. During this period of time, there was strong inflation, which exceeded the increase by 13 billion, so the dynamics is still negative;
- 2017 - 389 billion rubles.
Thus, it can be seen that the financing of the health sector is declining at a rapid pace. At the same time, the Minister of Health of the Russian Federation V. Skvortsova announced on September 28, 2017 that the federal part of the budget in 2018 will increase by 18.3% and will amount to 460.3 billion rubles. However, it is not known whether the draft budget will be approved by the State Duma.
Domestic innovations in the field of medicine
Despite the fact that, in general, the health care system in Russia is not doing well, this is not reflected in any way at the level of innovation. The state has always been famous for great minds, therefore, even in difficult years for the economy, some new discoveries and useful inventions appear in the Russian Federation. The TOP 5 medical innovations in the country for 2017 included:
- iHematologist.
This is an expert system that allows you to completely decipher a blood test, thereby diagnosing dozens of types of diseases. For this, a person does not even have to leave the house. All you need to do is enter your blood test data on the website. In return, the service will provide comprehensive information about the state of health.
- Life button.
This is a kind of mobile phone, on which there is only one button - emergency assistance. The gadget is equipped with a GPS navigator, which determines the location of a person with high accuracy. The data is sent to the round-the-clock service center, which communicates with the Ministry of Emergencies and other services. Such a system is designed to help elderly and disabled people who are not properly cared for.
- VitaVallis.
This is an antimicrobial sorption material developed by the Tomsk company "Akvelit". Its main purpose is to protect the body from various infections and viruses. It is a potential alternative to antibiotics. The principle of action is based on the natural mechanism of suppressing microbes inside the dressing. In other words, the infection is destroyed not toxicly (under the influence of antibiotics) but through physical processes.
- Oriense.
This is a device for helping visually impaired people. It is installed on a person's chest in order to analyze the environment. The built-in speech adapter instantly informs the person about the obstacles that are on his way, and options for how to get around them. Oriense is a resident of the Skolkovo International Center.
- 3D Bioprinting Solutions.
A Russian laboratory that has been developing technology for 3D bioprinting for many years. Speaking in simple words Is a technology that allows organs to be printed on high-tech 3D printers. The first demonstration of this project in operation was carried out in the summer of 2017.
As in all developed countries, there are separate clusters in Russia that support high-tech startups in the field of medicine. Innovations are being actively implemented not only in various areas of healthcare, but also in the system of interaction between a doctor and patients. For example, the Teledoctor service, recognized as the best startup in 2014, allows you to receive remote consultation from a specialist.
Conclusion
The situation in the healthcare system of the Russian Federation looks twofold: on the one hand, the number of medical institutions is sharply decreasing, on the other hand, mortality from diseases is decreasing, and innovative technologies appear on a regular basis that can change the life of mankind for the better. On the whole, there is a desire of the government to improve the situation, only the economic factor - an elementary budget shortage - hinders.
The transition from the paternalistic (total guardian) system of the Soviet state to the liberal model in the healthcare sector had negative consequences. The changes have had a very negative impact on the health of Russians - it has become worse in comparison with the Soviet period. In recent years, a vicious circle has emerged in which domestic health care has found itself: the more funds are invested directly in medicine (in specialized inpatient care and high technologies), the less funds are left for prevention and early detection of diseases. The lack of prophylaxis predetermines an increase in the number of patients, the detection of diseases at later stages, and the chronicity of pathologies. This, in turn, requires even more investment. A number of complex social problems of Russian health care follow from this:
The transition from mass health-improving and preventive measures to individual treatment, i.e. dominance of clinical medicine;
Increasing the cost of health care does not increase its effectiveness;
The increase in the payment for medicine, the constant shortage of funds, the lack of transparency in financial flows;
The deformation of humanism and medical ethics, which now makes it possible to see in the patient another source of income;
The sharp economic stratification of Russians, which predetermines an unequal attitude towards health and the possibilities of receiving medical care;
Inequality in the income of doctors themselves;
Shifting responsibility for health only on the population itself.
The main negative consequence of these problems is a decline in the population, unprecedented in peacetime. Today it is not as destructive a process as in the previous 18 years. There are tendencies towards stabilization of the number, but the "quality" of human health, degradation of the environment, a critical decline in the country's labor and defense potential are urgent threats. Demographic situation in the Russian Federation is still unfavorable, although the rate of population decline in recent years has significantly decreased - from 700 thousand people annually in 2000-2005 to 213 thousand in 2007. In 2008, the rate of natural decline in the population was 2.7 per 1000 population. As of 2010, the resident population in the Russian Federation was 141.9 million people. The decrease in the rate of population decline is mainly due to the birth rate and the decrease in mortality. In 2007, 8.3% more babies were born than in 2006 (1 million 602 thousand). In 2006, for the first time in 7 years, life expectancy began to increase - from 65.3 years to 67.5 years. Nevertheless, the average life expectancy in Russia is 6.5 years less than that of the “Young Europeans” (countries that have joined the EU since 2004) and 12.5 years less than in the countries of “Old Europe”. A big difference in Russia remains in the life expectancy of men and women - 13 years. The main reason for this is the high mortality rate among men of working age. The life expectancy indicator is a generally accepted indicator of the quality of life and health and a correct measure of the mortality rate. The main causes of death in Russia are:
Diseases of the circulatory system, from which, for example, about 1.2 million people died in 2007 (56.6% of the deaths);
Neoplasms (13.8%)
External reasons (11.9%).
It is very significant that oncological diseases
in Russia are characterized by a high proportion of deaths during the first year after diagnosis: for example, the percentage of deaths from lung cancer is 56, from stomach cancer - 55. This suggests that people go to the doctor late, when treatment is very costly, and the risks of death great. Working-age men die from cancer 2 times more often than women, although the incidence among women is higher.
In Russia, mortality from external causes is 4.6 times higher than in the countries of old Europe and 2.6 times higher than in “new” ones. These reasons are mainly:
Excessive consumption of strong alcoholic beverages;
Accident on the roads;
Suicide.
The most important indicator of the effectiveness of health care in any country is the average life expectancy of people suffering from chronic diseases. In Russia, it is 12 years, in the EU countries - 18-20 years. Disability in the Russian Federation has not decreased, including among the able-bodied, there are 14 million of them in the country, of which 523 thousand are children. This indicates the low quality of medical care and inadequate social rehabilitation.
The percentage of risk factors (high blood pressure, high cholesterol levels, tobacco smoking, alcoholism) in the structure of mortality among Russians is 87.5%. The first place among these factors is occupied by excessive alcohol consumption. This is a major public health problem in the country. Every day in Russia, 33% of boys and 20% of girls, about 70% of men and 47% of women consume alcoholic beverages (including low-alcohol ones).
In 2006, the priority national project "Health" was launched with four main directions:
Development of primary health care;
Strengthening preventive activities;
Increasing the availability of high-tech assistance;
Introduction of the generic certificate system.
In 2007, a pilot project to modernize healthcare was carried out in 19 constituent entities of the Russian Federation. In 2008. programs to improve care for patients with cardiovascular diseases who were injured in road accidents and a program to develop blood services began. In 2009, programs were launched to improve the organization of oncological care for the population and activities aimed at promoting a healthy lifestyle.
As a result of three years of efforts to implement projects, there was an improvement in demographic and health indicators of the population:
The birth rate has increased by about 16%;
Life expectancy increased by 2.2 years;
The overall mortality rate has decreased by 10%.
State intervention, increased funding, and finally, the personal control of top officials in this situation can be converted into a figure of 500 thousand saved lives of Russian citizens.
What systemic problems await Russian society and healthcare in the near future? First, demographic: the share of the elderly population in the Russian Federation will increase from 21% to 28%; secondly, a decrease in the birth rate due to a decrease in the number of women of childbearing age. Today, girls 10-14 years old, expectant mothers, are 2 times less than women of childbearing age. Finally, an increase in the prevalence of non-communicable socially-caused diseases. The necessary response to these challenges should be investments in the development of pediatrics and neonatology and an increase in the retirement age by 10 years. The first provision only requires funding. The second will not be immediately realized, since according to Rosstat, only 48% of men live in our country until the age of 65. It is necessary to extend the life expectancy of men by at least another 5 years, and then it will be possible to discuss the issue of extending the retirement age.
Two serious government documents were approved by the President and the Government of the Russian Federation - "The concept of the demographic policy of the Russian Federation for the period up to 2025" and "The concept of long-term socio-economic development of the Russian Federation for the period up to 2020". The latest document concerns all sectors, including healthcare. It sets goals: to reduce the mortality rate by 1.5 times by 2020 and to increase life expectancy to 73 years. The main principles of this strategy should obviously be:
Solidarity (the rich pays for the poor, the healthy for the sick);
Equality of urban and rural residents, wealthy and depressed regions;
Pluralism of opinions, openness and evidence-based decision making;
Lack of corruption.
The main direction of this strategy is the adaptation of the Semashkovo system of organizing medical care to modern conditions, increasing the efficiency of management. To solve these kinds of problems, health at the national level should be the object of research. The efforts of sociology, medicine, hygiene, and management economics will make it possible to determine trends in the health of individual regions and the country as a whole. To build an effective social policy to optimize the health of various groups of people, it is necessary to differentiate and determine the significance of the influence of the environment, lifestyle, and biological factors.
QUESTIONS AND TASKS.
1. What is the difference between the concepts of "health" and "public health"?
2. What parameters determine the health of a person?
3. List the main actors in the health care system.
4. What are the main problems of healthcare in the Russian Federation?
5. How do the social role and status of a medical worker correlate with his social prestige?
6. How are the states of the ecosystem and human health related?
7. Which of the lifestyle elements have the most noticeable positive and which negative effects on human health?
8. What are the main ways of solving social health problems in Russia?
9. In accordance with the Constitution of the Russian Federation, citizens are provided with medical assistance by state, private and municipal medical institutions. What, in your opinion, should be the ratio of these types of institutions? What are the advantages and disadvantages of each of them?
Chapter 11. SOCIOLOGY OF FAMILY AND MARRIAGE.
1. Family as a social institution and social group.
2. The origin and historical types of the family.
3. Typology of the modern family.
4. Social functions of the family.
5. Family life cycle.
6. Family structure and types of family relationships.
7. The institution of marriage.
8. Problems and prospects for the development of family and marriage relations.
Basic concepts: sociology of family and marriage, family group, family structure, social functions of the family: reproductive, educational, economic, recreational, social status, regulatory, medical; family life cycle, family types: traditional, neo-traditional, egalitarian, partner, extended, patriarchal, incomplete, nuclear, childless, large; marriage, types of marriage: endogamy, exogamy, polygamy, polygyny, polyandry, monogamy, early marriage, child marriage, purchase-redemption, church, legal (civil); family law: marriage, rights and obligations of family members, forms of responsibility, divorce, motives and reasons for divorce.
FAMILY AS A SOCIAL INSTITUTION AND A SOCIAL GROUP.
The family is one of the main foundations of society and one of the most important human values. This is a complex social formation in which various forms are intertwined. public relations and which performs numerous functions necessary for society and man. The family can be viewed as a social institution and as a small social group.
Family– it is a social group with a common place of residence, economic cooperation, a system of social and emotional relationships. The family includes adults of both sexes who maintain a socially sanctioned sexual relationship and, as a rule, have one or more children (their own or those taken into foster care).
As a small social group, a family is a collection of people united by marriage or consanguinity and having coinciding interests in the field of organizing everyday life, mutual assistance and mutual responsibility for the health and well-being of family members. It unites a whole spectrum of interests and relationships of various kinds: emotional, spiritual, economic, sexual, etc. It is the most cohesive and stable unit of society, the group with which a person always keeps in touch.
How social institution, it includes a set of roles and statuses, norms, values, sanctions and patterns of behavior that govern the relationship between spouses, parents, children and other relatives. The family is the main institution of human society. This institution includes several more private institutions: marriage, kinship, motherhood and fatherhood, property, etc. In turn, the institution of marriage includes institutions of courtship, matchmaking, betrothal, etc.
In addition to sociologists, the family is studied by historians, economists, ethnographers, lawyers, politicians, demographers, and even recently emerging disciplines that claim to be a synthetic approach - "surname studies" and "feminology". Hence, there are significant differences in the definition of the very concept of "family".
So, from the point of view sociology a family is a small social group based on marriage and consanguinity, whose members are linked by a common life, mutual assistance, moral and legal responsibility. This is a system of status-role relationships between husband and wife, parents and children. As a social institution, it interacts with society, the state and other social institutions. That is, from the point of view of sociology, the family is a really and actually existing small group, regardless of how it arose, what procedures, ceremonies and rituals accompanied its emergence. Another important characteristic of the family is the continuity of generations. . Sociology understands the family as such an integrity that is divided and restored in each generation.
From point of view economic, a family is a group of people who live together and have a common household. But living together and running a joint household is not a sign of a family, but households. The household is often broader than the family in its composition at the expense of persons who are in common with the family and even live together, but are not in kinship relations with family members. Such persons can be educators, nannies, home teachers, employees, if they live with the families of the employers. It can also be those whom the family has adopted in order to support financially or because of the inability to serve themselves. A household is an individual, family or several people living in a hostel or in a rented apartment and leading a common household (food, home care), but not necessarily related. Therefore, an addition is required: family is a household, i.e. a group of people living together, united by kinship or property, and general budget(joint ownership).
Historical the aspect of the institution of the family is studied by historians, ethnographers and anthropologists, who consider the family, primarily from the point of view of the typology of marriage, kinship, types of family. The concepts of exogamy and endogamy, monogamy and polygyny, patriarchal and matrilineal came into sociology from these disciplines.
The history of the institution of the family in different cultures is a subject of cultural and social study anthropology. These directions in science clarify the kinship system, types of marriage, roles and statuses in the family, the genealogical tree, rituals of betrothal, matchmaking, birth, death, naming, the position in society of widows and widowers, bachelors and divorced, orphans and illegitimate children.
The concept of "family" is closely related to the concept of "marriage", and so closely that in everyday life they are often used as synonyms. However, if the family is an institution that regulates relations between spouses, parents and children and other relatives, then marriage, on the one hand, is secondary, since it is an institution that regulates relations only between a man and a woman, between the sexes, and on the other hand, the institution of marriage is primary. in relation to the family, because the family begins to exist only after the conclusion of marriage - a kind of "social contract, the obligation of spouses to comply with certain rules proposed and approved by society." The family is the result of marriage, and marriage is the gateway to the family. Different forms of marriage in history and modernity reflect both a certain level of development of the corresponding society, and historical, religious, national traditions. This results in different ways of creating a family, different structure, differences in functions, etc.
The problems that have accumulated in Russian healthcare are causing serious concern in society, and there has practically been a consensus that significant changes are needed in this area. This is evidenced by both objective and subjective indicators characterizing such parameters of the Russian health care system as - the state of health of the population; - the state of the health care system itself; - assessment of the state of their health by the population and its attitude to the health care system in general and reforms in particular.
The subjective assessment of the state of their health by the population confirms the statistics. Opinion polls show a low self-esteem of the population of the state of health. The population's subjective assessment of the health care reform is rather cautious. This indicates that there has not yet been a significant improvement in the health care system.
I would also like to draw attention to the global challenges to health systems that have emerged to date in developed countries. The health care system can be organized in different ways, but at present, health care as a system on a global scale is experiencing serious problems that require a response and will obviously determine its organization in the future. Population aging has become a major socio-demographic problem in developed countries. On the one hand, there is an increase in demand for medical services, and on the other, an increase in the demographic burden on workers, which complicates the problem of financing health care. The increase in demand for medical services is also caused by the development of modern technologies, which provide new opportunities in the field of treatment of various diseases, and, accordingly, the basis for the emergence of new expectations from the population.
The growing inequality in access to health care is noted by many professionals, despite the fact that this issue has recently attracted attention at the highest levels. There is a change in trends in the state of health and the structure of morbidity of the population. Chronic diseases are coming to the fore in developed countries, which require different approaches to the organization of treatment and prevention than infectious diseases.
Threats to health arise from human actions, human-environmental interactions and accidents and natural disasters. These include the problem with vaccination. Voluntary vaccination in many countries and a false sense of security, when high vaccination rates reduce the risk of illness and parents refuse to vaccinate, can in turn lead to lower vaccination rates, increased risk of illness and the outbreak of epidemics. The evolution of viruses and the increase in their resistance to the corresponding drugs leads to the emergence of new and the resumption of already known infectious diseases. Epidemics of infections such as HIV and avian influenza have emerged. The other side of the risks is associated with human activities. The life of society has become largely dependent on atomic energy and chemical processes. Therefore, the epidemiological situation depends on the safety of the appropriate facilities and the correct use of the products obtained.
Paradoxically, the National Health Project has become a litmus test of the problems of the Russian healthcare system. It turns out that all the latest achievements of Russian healthcare are reduced to those results that were achieved within the framework of the tasks set in this project. At the same time, it is often argued that some stabilization in the health care system in 2005-2007. was achieved at his expense. However, many demographers and experts point out directly that the increase in the birth rate in recent years is directly related to the entry into active reproductive age of girls and boys born in the late 1980s. The question also arises about the role of the rest of the health care system in the ongoing positive changes, which was not included in the national project. Although the latter brought some positive results, they were not achieved within the existing health care system, but outside it, which actually confirms the fact that it is ineffective and, in general, is not able to implement positive changes without an additional push from the outside, for example, in the form national project.
Another issue is related to the problem of maintaining and developing the health care system. Today, three basic models of organization and financing of health care are known, and Russia became the author of one of them (the Semashko model). Specific forms are determined by the specifics of the functioning of the system, which a country can afford, depending on the characteristics of its development. New models of healthcare emerged in the world when there were changes in the worldview, changing the formulation and vision of the problem. The proposed options for the development of Russian health care, including the draft Concept for the development of health care in the Russian Federation until 2020, developed under the auspices of the Ministry of Health of the Russian Federation, or the project proposed by the Public Chamber, adapt to the situation in which Russia finds itself today and which was set in the early 90s. x years of the twentieth century. But the speed of social change requires that the predictive function, which determines how this or that system will behave in the long run, becomes the leading one. The creation of "one-day" in these conditions can be costly for society. It seems that the onset of the crisis is not the best time for global changes. Lessons can be learned from the experience of the early 90s, when most of the failures in health care reform are due precisely to the fact that the insurance system was introduced in difficult economic conditions, when the base for insurance premiums is deliberately narrowing.
Therefore, in modern conditions, an integral part of the strategy for the development of Russian health care should be the development of mechanisms for adapting to crisis situations.
There are objective system-forming factors that will potentially cause problems in the development of healthcare in Russia as a system. The extent to which they are taken into account in the formation of the reform strategy depends on the success of the measures taken.
One of the threats is related to the volume and method of healthcare financing in Russia. The question of how much money Russia should spend on health care remains open. It would seem that the increase in health care costs should be welcomed. However, a phenomenon is emerging that can be conventionally called a funding growth trap. This means that the option chosen in the context of limited resources allocated by society for health care is initially costly and leads to the need to increase financing for health care in the future.
The main motivation for health care reforms in the 90s was the lack of public funds and the need to mobilize resources from other sources. But the paradox of Russian health care policy is that, on the one hand, budget medicine has no equal in curbing health care costs, on the other hand, Russians are constantly being taught that there are not enough funds for health care, but at the same time they choose the initially costly option (insurance ), ignoring or even openly denying the relatively less costly (budgetary) system.
Relatively less costly means that such a system provides equal and relatively better health outcomes for the general population at relatively lower costs. The United Kingdom and the United States can be cited as examples. A comparison of health financing and health outcomes in these countries shows that although the United States spends almost twice as much on health as the United Kingdom, with a significant share of private funding sources, the health outcomes in these countries are comparable, and some are even slightly better, in the United Kingdom. For example, maternal mortality in the UK is lower than in the US (11 and 14 per 100,000 live births in 2010, respectively), and healthy life expectancy at birth is higher (69 years for men and 72 years for women in 2010 in the UK and 67 years and 71 years, respectively in the United States). In recent years, obesity has become a major public health problem in the United States, which affects almost one third of the population, both men and women over the age of 15.
There are various approaches to determining the share of spending on health care, taking into account the willingness of the population to finance it. You can set standards minimum costs states taking into account world experience. However, it is important not only how much funds are spent, but also through which funding mechanism the reallocation is carried out. In Russia, we are talking about chronic underfunding and the need to increase health care costs, while in developed countries the issue is about curbing the growth of health care costs. Taking into account global trends, our country needs to initially choose a financing system option that will turn the allocated funds into an effective system for providing high-quality medical care to the population, and not just increase health care costs.
It is appropriate here to recall such an approach as managerialism, which is widely recognized in the world and claims that improving management and organization is an important reserve for increasing the efficiency of any structure. In this context, we can talk about a wide range of actions, from changing the structure of the health care system in favor of primary health care and prevention, to “medicine with a human face” or “policy of small achievements”, implying the use of modern management technologies for organizing work in medical institutions, allowing to realize a human attitude towards patients with minimal additional costs.
In this regard, the assertion that if there is a demand for medical services (implied by high-income groups of the population), then it is necessary to ensure its satisfaction, is also controversial from an economic point of view. It seems that the characteristics of a medical service as a product, which are widely known and described in the world literature, put in the first place the question of satisfying a need, not a demand. The growth of costs will also be facilitated by linking the payment of medical workers to the volume and quality of care provided.
The benefits of government funding are well known: control over funds and ensuring the implementation of national priorities, the main of which is the access of the population to health care. Centralized systems are effective enough to contain the growth of health care costs. Obviously, the budgetary health care system has both advantages and disadvantages, but analysis of different health systems shows that the adoption of other models will lead to a number of new problems.
Another threat to the integrity and, accordingly, the effectiveness of healthcare in Russia as a system acting in the interests of society is associated with the growth of inequality in society, both at its general level and in the state of health. At the same time, world theory and practice convincingly prove that inequality in health is a serious obstacle to economic growth.
One of the important factors of inequality in health is the level of income. Given the high level of income inequality that has now emerged in Russia - in 2006, the Gini coefficient on average in Russia was 0.410 - objectively, significant differences arise in the socio-economic status of patients. In the conditions of the fundamental stratification of Russian society, it is already difficult to find an "average patient" - the rich and the poor have different needs and financial opportunities to receive medical attention. The availability of wealthy people able to pay for health services stimulates the development of the private sector. Moreover, in this regard, it is necessary to keep in mind two aspects. One is related to the profit motive in healthcare, and the other is related to the innovative potential of entrepreneurship.
The task of any commercial structure is to make a profit. Healthcare in this sense is a very sensitive industry, also due to the special relationship that develops between a doctor and a patient due to the peculiarities of the medical service and the process of its provision. On the one hand, the patient will have more confidence in the doctor who acts without a profit motive, on the other hand, the doctor has an objective opportunity to “increase the bill”. Therefore, tight regulation is needed, possibly at the level of the rate of return.
Usually, private medicine develops as a complementary to more socialized forms. However, the situation is controversial, as there is a process of “skimming” or selecting the best clients. For example, in the UK, the private sector, including voluntary health insurance, is quite inexpensive due to the presence of a developed public sector. Most patients additionally use the National Health Service (NHS), even if they have voluntary insurance especially if the patient has a complex problem and the private hospital simply does not have the capacity to treat it; usually additional insurance these are young, healthy and well-paid people at work, that is, a group of minimal risk.
A special role is assigned to business as a leader in innovations in medicine. The innovative potential of entrepreneurship is well described, but in medicine this process also cannot be assessed unambiguously. The development of medical technologies is an expensive process, which is one of the main factors in the growth of health care costs in developed countries. Therefore, a contradiction may arise next order... From the point of view of making a profit, business is more profitable from high technologies, since they are more expensive, and from the point of view of efficient and fair distribution of limited resources, it is more profitable for society to develop relatively cheaper primary health care. It is proposed to look for compromise options for business development as a provider of medical services on the path of public-private partnerships.
So far, the private sector is complementary and serves to expand consumer choice. But if it grows above a certain level, then it is possible that the most demanding consumers will leave the public sector, thereby reducing the pressure on the state to increase health care costs. This will lead to the formation of a two-tier system - high-quality medical care in the private sector for the wealthy and low-quality care in the public sector for the rest. This situation creates the risk of rupture of the health care system and marginalization of the poor. Therefore, at present, it is necessary to choose a health care system that will keep the health care of Russia as a system for providing affordable and high-quality medical care to the population while maintaining the basic principle of social solidarity.
The experience of developed countries shows that, despite liberal reforms, the role of the state in providing the population with social services and redistribution is still on the agenda. Liberal politics led to an increase in social division and therefore a need arose for a strategy of integration within the framework of a market economy. In these conditions, the state health care system can become the basis for social consensus and overcoming the social disunity of Russian society.
Thus, at present, the Russian health care system is faced with both specific problems caused by the peculiarities of its socio-economic development, and with general problems arising in the field of ensuring the health of the population and having a global character.
Introduction
1. The concept and history of the formation of healthcare in Russia
1.1 Concept of health care
2.3 Inconsistency of legal regulation of the healthcare sector
3.2 Ways to solve problems government controlled in health care
1.2 The history of the formation of healthcare in Russia
Late 17th - early 18th century became a significant time in the history of Russia. The reforms of the outstanding statesman and commander, the talented and energetic Peter I, made it possible to overcome the cultural self-isolation of Russia (which, however, was never absolute), to open a “window to Europe”, to establish contacts and exchange, to join the common European culture and civilization. Peter's reforms, the exertion of the popular forces, the labor of all of Russia helped in many respects to eliminate the backwardness of the state, played a huge role in the development of the country's productive forces, its industry and Agriculture, science and culture. As the great Pushkin wrote about this time, “there was that troubled time when young Russia, straining her strength in struggles, matured with the genius of Peter” 1. Russian medicine was also gaining strength and experience.
Peter I was an educated person, highly valued science. According to the famous historian V.O. Klyuchevsky, he was imbued with faith “in the miraculous power of education” and “reverent cult of science” 2. What is especially characteristic, Tsar Peter, according to his contemporaries, had a genuine passion for medicine. When in 1697 he visited Holland and England as part of the Great Embassy, under the name of the sergeant Peter Mikhailov, he got acquainted there with medical clinics and anatomical laboratories.
They say that Peter listened to the lectures of professor of anatomy Ruysch, was present during operations, and when he saw in his anatomical office the perfectly dissected corpse of a child who smiled as if alive, could not resist and kissed him (later Peter bought the anatomical collection of Professor Ruysch, she was in St. Petersburg, in the Kunstkamera and the Academy of Sciences).
In Holland, Peter I met with the famous naturalist, one of the founders of scientific microscopy, Anthony van Leeuwenhoek, who, at the request of the king, arrived on his ship. The Dutch scientist “had the honor, besides his other rare discoveries, to show the Emperor, to his great delight, the amazing circulation of blood in the tail of an eel with the help of his special magnifying glasses; Thus, two hours passed in various observations, and, leaving, the king shook Levenguk's hand and expressed special gratitude to him for the opportunity to see such unusually small objects ”3.
There is a legend that in Leiden he also looked into the anatomical theater to the famous professor Boerhave, a medical luminary of that time, saw how the professor “separated” the corpse and “told” the students about its parts, and then examined the richest collection of preparations, embalmed and “in alcohol ". By the way, having noticed that some of the retinue accompanying him expressed disgust for the dead body, Peter became very angry and forced them to tear apart the muscles of the corpse with their teeth.
“The spread of medicine in our country under Peter the Great was greatly facilitated by the monarch’s passion for anatomy and surgery,” noted the historian of medicine N. Kupriyanov later. - ... In surgery, the emperor acquired many knowledge and even practical skills. As a rule, the monarch carried two sets with him: one with mathematical instruments, the other with surgical instruments and loved surgery so much that under the leadership of Termont (this surgeon came to Russia during the reign of Tsar Alexei Mikhailovich - MM) methodically opened corpses, made incisions, bleeding , bandaging wounds and pulling out teeth. The tsar ordered to report on every more interesting operation performed in a hospital or a private house. The monarch not only watched the operations, but did them himself. "
A skilled craftsman, Peter knew many crafts perfectly. Success in this instilled in him a strong confidence in the sleight of his hands: he really considered himself both an experienced surgeon and a good dentist. It happened that close people suffering from any ailment that required surgical help were horrified at the thought that the tsar might find out about their illness and, having appeared with instruments (Peter I had his own surgical instruments, which included a pair of lancets, knife, pliers for pulling teeth, scissors, a probe for wounds, etc.), would offer his services as a surgeon: of course, it was impossible to refuse the king, but it was also impossible to trust him as an operator, as a doctor, as a healer. Still, as they say, after him there was a whole sack with his teeth pulled out - a monument to his dental practice.
During the reign of Peter I, which in fact opened the history of Russia in the 18th century, the state character continued to be a distinctive feature of the organization of medical business in the country. Despite the difficulties associated with large-scale reforms, the state tried to take care of the health of its citizens, especially the military, spending certain amounts from the budget and managing all medicine in the country.
It is known that during the reign of Peter I, large military hospitals were opened in Russia - in Moscow (1707), Petersburg (1716), Kronstadt (1720), Revel (1720), Kazan (1722), Astrakhan (1725) and other cities of the country. ... By a decree of Peter I (1721), magistrates undertook to build "zemstvo dependent state hospitals for the charity of the orphan, the sick and the crippled and for the elderly people of both sexes": as a result, during his lifetime, 10 hospitals and over 500 infirmaries were created in the country. In 1715, when he laid the foundation for a naval (Admiralty) hospital in St. Petersburg, on the Vyborg side, Peter I said: “Here, the exhausted man will find help and comfort, which he had hitherto lacked; God only grant that many never need to be brought here! "
It should be emphasized that it was Peter I who provided state support for the measures taken by the Orthodox Church and many of its monasteries to combat "foundlings" and to help orphans and illegitimate children; he especially actively supported the initiatives of the Novgorod Metropolitan Job. Back in 1706, Metropolitan Job, using the monastic income, opened three hospitals on the banks of the Volkhov River, as well as a house for passers-by and "a house for illegitimate and all kinds of thrown babies." For this "home of thrown babies" a whole monastery in Kolmov was allocated. A. Gorchakov in his book "Monastic Order" (1863) reports that Metropolitan Job in 1714 had "10 strangers, 15 beggars or hospitals and a house for foundlings."
The highly useful activity of Metropolitan Job Peter often cited as an example not only to the hierarchs of the Church, but also to his closest circle: Christian charity was becoming an important state affair. Moreover, in a decree of January 16, 1712, Peter I directly prescribed: "In all the provinces to make tapestries for the crippled, as well as unseen reception and feeding of babies who were born of illegitimate wives, following the example of the Novgorod archirew".
In another tsar's decree, it was emphasized: “In the same way, about the same things, the blessed Job, Metropolitan of Novgorod, made a thorough and soul-saving examination of the same deeds in Veliky Novgorod, to choose skillful wives to preserve the shameful babies whom wives and girls give birth to illegally ... Announce the decree so that such babies are not swept away to obscene places ... "
Even in the notebooks of Peter I there are notes indicating that he paid great attention to these undertakings. For example, here is a note made by Peter I at one of the sessions in the Senate:
“Was it done according to the decree on lifting babies, as the Novgorod arch-father Job had. And if not done - why. "
The developing medicine required the expansion of the supply of medicines to the population. Therefore, much attention has been paid to increasing the number of pharmacies. State pharmacies were opened in St. Petersburg, Kazan, Glukhov, Riga and Revel in 1706, and in some other cities - garrisons. At the same time, measures were taken to encourage the creation of free (private) pharmacies.
In 1701, a decree was issued that any Russian or foreigner who wishes to open a free pharmacy with the permission of the government will receive a place without money necessary for this and a letter of gratitude for the hereditary transfer of his institution; such pharmacists were given the right to freely prescribe all the necessary materials from abroad. In Moscow, in addition to two state-owned, it was allowed to open eight more pharmacies. And from 1721, free pharmacies began to open in St. Petersburg and other provincial cities. It is characteristic that both the permission to open pharmacies and control over their activities were in the sphere of state interests. State medicine, primarily the military medical service, required more and more doctors. At first they were recruited abroad. For example, only in 1698 in Amsterdam, along with captains, gunners, navigators and other specialists, were hired, along with captains, gunners, navigators and other specialists, to serve in Amsterdam: each was entitled to a salary of 12 efimks, 13 altyns and 2 money per month10. All these doctors studied medicine not at universities, but as individual apprenticeships with other, more experienced doctors, and then served in the troops or on ships of various European countries.
To find their own, more qualified doctors, it was necessary to train their own doctors in the country, opening special educational institutions for this purpose. And in the 18th century, after the first hospital school in Moscow, several more schools were opened. Pupils of hospital schools, who were equally competent in therapy and surgery, were sent primarily to the army and the navy.
It is generally recognized that economic progress and the associated political and cultural transformations inevitably determine the need for the rapid development of science. So it was in our country.
Already in early XVIII v. a school of mathematical and navigational sciences (1701), artillery schools (1701), an engineering school (1713), a naval academy (1713), mining and craft schools (1719) and a number of others appeared in Russia: the Petersburg Academy of Sciences (1725), and then and Moscow University (1755). Among the first in Russia, a medical-surgical (hospital) school was opened and trained doctors.
It is important to emphasize that this school represented a fundamentally new type of higher medical educational institutions. The main thing is that, unlike the one that existed in the 17th century. the medical school of the Apothecary Prikaz, which was discussed above, and the first, and all other Russian medical and surgical schools were created only on the basis of large medical institutions - hospitals, which is why at first they were called "hospital".
From the very beginning, the establishment of large, general (i.e. educational) hospitals pursued a twofold goal - the treatment of patients and the teaching of medicine. “The institution of hospitals has a double intention and fruit,” the General Regulations on Hospitals, approved in 1735, legitimized: the first and which has the authority to be - the use of suffering patients, the second - the production and approval of doctors and doctors to great art; for the sake of this intention, although in the beginning, physicians and healers should be provided. "
The hospital schools created in Russia were fundamentally different from the medical educational institutions that existed in Western Europe - the medical faculties of universities. As you know, their graduates - doctors of a therapeutic profile - received primarily a theoretical education. In contrast, surgeons with no university medical education received practical training in the "craft apprenticeship" method and were considered second-class physicians. However, life showed - and at the beginning of the XVIII century. it became more and more evident that physicians should be well trained in both internal medicine and surgery.
In Russia, where the antagonism between doctors and surgeons inherent in Western Europe never existed, from the very beginning of higher medical education they began to train doctors who were equally competent in surgery and internal medicine. Higher medical education began in Moscow.
On May 25, 1706, a decree of Peter I was published on the organization of the Moscow "gof-shpital": it should have been built "across the Yauza River, opposite the German settlement, in a decent place ... for the treatment of sick people." The decree emphasized: “And that treatment will be for Dr. Nikolai Bidloo, and two doctors Andrei Repken, and the other, who will be sent; yes, from foreigners and Russians from all ranks of people to recruit 50 people for the pharmaceutical (ie, medical. - MM) science; and for the building and for the purchase of medicines, and for all sorts of things belonging to that, and for the doctor, and doctors, and disciples for the salary, to keep money from the fees of the Monastic Order. "
Initially, several wooden two-storey outbuildings were built for the hospital - as they were then called, "houses with light rooms". The hospital buildings were surrounded by a garden in which medicinal plants were planted.
On November 21, 1707, the hospital was opened, patients began to be admitted here for treatment. “All-merciful sovereign,” wrote the head of the hospital, Dr. Bidloo to Peter I, “your imperial majesty was pleased to have ordered the hospital at Yauza to be built, which, with God's blessing, under the care of his Excellency Count Musin-Pushkin (at that time the manager of the Monastic Order. - MM) On November 21, 1707, he was brought into such a state that with it in God's name a beginning was made, and for the first time several sick people were brought into that house. "
At the same time, the country's first Moscow hospital (medical-surgical) school began to operate, and its first students began to study. On the maintenance of the hospital and the school, the Monastery Prikaz (and then the Holy Synod, which replaced it) spent part of the funds received by the clergy from the monastic estates, from fees from the “crown memorials” (they were paid upon marriage), from “hospital money” (a kind of tax on medicines collected from all government officials), from “fines money” (for more than a year overdue spiritual confession).
To study at school, knowledge of the Latin language was required - teaching was carried out in this traditional international language of science, so the school initially enrolled students of the Moscow Slavic-Greek-Latin Academy and theological seminaries. These were young people of democratic origin, people from the lower strata of society, primarily from the petty clergy, from the townspeople and artisans, from the Cossacks and soldiers; there were also medicinal children among them. The majority were "natural Russians", but there were also children of foreigners. Forced to achieve everything by their own labor, they regarded learning as labor and for the most part did it with great eagerness.
However, not all of those who entered the Moscow hospital school completed the full course of study. So, in 1712, Dr. Bidloo wrote to Peter I: “I took in different years and numbers 50 people before surgical science, of which 33 remained, 6 died, 8 fled (from schools then, as V.O. Klyuchevsky wrote, very many young people. - MM), 2 were taken to school by decree, 1 for intemperance was sent to the soldiers. " According to age, duration of schooling and success in learning, all students were divided into three articles (categories) - the first, second and third. All of them studied for free and were at full boarding school with the state, lived at the hospital in separate rooms, had a common table, received uniforms and a salary. The salary was 1 ruble a month, cloth for a caftan, a camisole and trousers was issued for uniforms - 7 yards each for two years: the quality of the cloth given out depended on the article in which the student consisted.
Initially, there was no fixed period of study at the Moscow hospital school - depending on the student's success, it ranged from 5 to 10 years. The training program provided for a thorough acquaintance with the subjects that then constituted the basis of medical and surgical education. These were, firstly, anatomy, and secondly, "Materia Medica", which included pharmacognosy (systematic botany), pharmacology and pharmacy, thirdly, internal diseases and, fourthly, surgery with desmurgy.
Anatomy, then the most important discipline in medical education, was taught by Bidloo himself.
Nikolai Bvdloo, or, as he was called in Moscow in the Russian manner, Nikolai Lambertovich Bidloo, was born in Holland, in Amsterdam, around 1670. His father Lambert Bidloo was a pharmacist and botanist, a member of the Amsterdam Medical Society, and his uncle Gottfried Bidloo - an anatomist and surgeon - at one time was the life-doctor of the English king, and then - professor and rector of the famous "Leiden-Batavian Academy". Nikolai Bidloo graduated from this academy, in 1697 he defended his dissertation on the topic "On delayed menstruation" and until 1702 was engaged in medical practice in Amsterdam. The Russian envoy to Holland, Count A.A. Matveev, by order from St. Petersburg, invited Bidloo to Russia as a physician-in-chief of Peter I and signed a corresponding contract with him. In 1702 Bidloo came to Russia, which became his second homeland: he lived here for more than 30 years and died in Moscow in 1735.
For several years Bidloo was the physician of Peter the Great: his duties included constantly accompanying the tsar on his extremely frequent trips across Russia. In addition, Bidloo carried out numerous assignments of the king, who was always interested in medicine.
In Leipzig at the beginning of the 18th century. the magazine "European rumor" was published, which covered the most important political events, the court chronicle was printed, etc. Among the important news from Moscow, "European rumor" published a message that "an anatomical theater was built in Moscow, which was entrusted to the supervision of Dr. Bidloo, a Dutch and the royal physician; he often anatomizes the bodies of those who have died by ordinary death, and those who have died from wounds, and the king himself is often present with the nobles, especially when doctors are consulted about the properties of the body and the causes of various diseases. "
However, numerous duties began to weigh on Bidloo, and he turned to the king, who was well pleased with him, who, moreover, for health reasons did not need the services of a physician, with a request to give him another service. So Bidloo became the chief doctor of the Moscow hospital and director of the hospital school, where he taught anatomy and other basic subjects.
Particular attention was paid to the study of anatomy at the Moscow hospital school: knowledge of this science was mandatory for surgeons. “Surgery,” taught future doctors, Dr. Bidloo, “refers so that the surgeon knows: 1. Anatomy, which is the knowledge of the whole human body from the outside and from the inside” 17. A similar anatomical (and later anatomical and physiological) approach, which was widely developed not only in Moscow, but also in other hospital schools, became a regularity that distinguished Russian surgery and medicine in the 18th-19th centuries.
The discipline “matter of medicine” (or, in other words, pharmaceutical science) was taught to the students of the hospital school by the hospital's pharmacists Christian Eichler, and then by Ivan Maak. The hospital had its own garden of medicinal plants (the so-called pharmaceutical garden): in the summer and autumn, the students, together with the pharmacist, went out of town, in the vicinity of Moscow, to collect medicinal plants and replenish the hospital pharmacy.
Since then complex medicines dominated medical practice - tinctures, elixirs, decoctions - from many different ingredients (sometimes from 20-30), students had to write down a large number of long recipes and store them for a long time. They were also given an idea about the then known pharmacopoeias, especially the so-called London one. Along with medicinal plants, students were taught to use such exotic, but used medicines as dog and fox fat, wolf teeth, antler, hare's ankles, etc. for treatment.
Internal medicine (or simply medicine) included private pathology and therapy. Their study was initiated by Dr. Bidloo.
Bidloo himself taught surgery to the students of the hospital school - only desmurgy ("the establishment of bandages") was taught by his assistant, the doctor Repken, and the doctor Fyodor Bogdanov.
Thus, the training program for future doctors at the Moscow hospital school was very rich, in no way inferior, and in some way superior to the programs of medical faculties of the then Western European universities, in most of which the deadening spirit of medieval scholasticism still dominated. The main thing, of course, was in the practical training of future doctors, in teaching students at the patient's bedside, in the hospital ward.
The glorious time of the reforms of Peter I had a beneficial effect on Russian medicine. As a matter of fact, it was Peter I that Russian medicine owes a lot to the fact that in the 18th century. it developed mainly like medicine in other European countries, on the basis of science and thoughtful recommendations, whether it concerned the training of doctors, or the fight against epidemics, or the activities of the military medical service. Wherein hallmark Russian medicine continued to remain its state character.
The training of medical personnel was carried out in hospital schools (from 1707), medical-surgical schools (from 1786), and from 1798 - at the St. Petersburg and Moscow medical-surgical academies. In 1725 the St. Petersburg Academy of Sciences was opened, and in 1755 the first in the country Moscow University with a medical faculty was created.
An outstanding contribution to health protection was made by M. V. Lomonosov, who in his work “The Word on the Reproduction and Preservation of the Russian People” gave a deep analysis of health care and proposed a number of specific measures to improve its organization.
In the first half of the XIX century. the first scientific medical schools are formed: anatomical (P.A.Zagorsky), surgical (I.F.Bush, E.O. Mukhin, I.V.Buyalsky), therapeutic (M.Ya. ... NI Pirogov creates topographic anatomy and military field surgery, in which he put forward the position on the importance of organizing medical care during hostilities, emphasized the extremely high role of preventive medicine. NI Pirogov was the first in the world in military field conditions to use ethyl ether for anesthesia (1847), developed many methods of surgical treatment, which are still classic, the first in the country to use female labor in war (1853).
2. Analysis of the national project to improve health management
2.1 New in Russian healthcare legislation
From 01.01.05 the Federal Law "On Amendments to legislative acts Of the Russian Federation and the recognition as invalid of some legislative acts of the Russian Federation in connection with the adoption of federal laws "On Amendments and Additions to the Federal Law" On General Principles of Organization of Legislative (Representative) and Executive Bodies of State Power of Subjects of the Russian Federation "and" On General Principles of Organization local government in the Russian Federation "from 22.08.04 No. 122-FZ. In accordance with this law, amendments have been made to 196 legislative acts, including 10 federal laws in the field of public health protection.
The bulk of the amendments were introduced in order to delineate powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local government bodies, which radically changed the entire system of interbudgetary financial relations within the Federation, including health financing.
In accordance with Art. 35 of the new law, amendments were made to the Fundamentals of Legislation of the Russian Federation on the Protection of Citizens' Health dated July 22, 1993 No. 5487-1.
In the article defining the powers of federal government bodies in the field of health protection (Article 5), the articles defining the powers of government bodies in establishing the structure, organization and operation of federal government bodies of the state health care system were declared invalid. Also excluded from the Fundamentals are the powers to determine the share of health care costs in the formation of the federal budget, trust funds intended to protect the health of citizens, the definition of tax policy (including benefits on taxes, fees and other payments to the budget) in the field of health care. This is due to the fact that the structure and procedure for the organization and activities of federal executive bodies are regulated by the Federal Constitutional Law "On the Government of the Russian Federation" and cannot be regulated by special legislation on the protection of the health of citizens. Formation of the federal budget and tax policy are determined by the Budget and Tax Codes of the Russian Federation and also cannot be regulated by special legislation on health protection.
The powers of federal bodies of state power to determine the range of specialties in health care have been supplemented by the powers to determine the range of organizations in health care. This is due to possible changes in the near future in the legislation on the organizational and legal forms of organizations, including healthcare organizations.
The powers to establish benefits for certain groups of the population in the provision of medical and social assistance and drug provision have been excluded. These and all subsequent exceptions to the legislation of benefits for various categories of the population are associated with "bringing the system of social protection of citizens who enjoy benefits and social guarantees and who are provided compensation, in accordance with the principle of delineation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local governments, as well as principles the rule of law with a socially oriented market economy "(preamble to the law).
In our opinion, the powers to issue permits for the use of new methods of prevention, diagnosis and treatment, new medical technologies, have been introduced into the powers of the federal bodies of state power, in our opinion. Previously, these powers belonged to the powers of the constituent entities of the Russian Federation.
Part 2 of this article was declared invalid, and therefore, in accordance with the current legislation, to date, certain powers in matters of protecting the health of citizens cannot be transferred by the Russian Federation to the constituent entities of the Russian Federation and the constituent entities of the Russian Federation cannot transfer their powers to the Russian Federation. This corresponds to the concept of the law on a strict delineation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local government bodies.
In the article defining the powers of the bodies of state power of the constituent entities of the Russian Federation (Article 6), a number of powers of the bodies of state power of the constituent entities of the Russian Federation are set out in new edition, which led to a change in the content of the powers. The powers of the state authorities of the constituent entities of the Russian Federation include the development and implementation of programs for the development of health care, prevention of diseases, the provision of medical care, medical education of the population and other issues in the field of protecting the health of citizens; establishment of the structure of governing bodies of the state healthcare system of the constituent entities of the Russian Federation, the procedure for their organization and activities; development of healthcare institutions in the constituent entities of the Russian Federation; their material and technical support; control over compliance with the standards of medical care in the manner prescribed by the legislation of the Russian Federation and the legislation of the constituent entities of the Russian Federation; the formation of expenditures of the budgets of the constituent entities of the Russian Federation for health care in terms of the provision of specialized medical care in dermatovenerologic, anti-tuberculosis, narcological, oncological dispensaries and other specialized medical organizations in accordance with the nomenclature of medical organizations approved by the authorized federal executive body (with the exception of federal specialized medical organizations , the list of which is approved by the Government of the Russian Federation), including the provision of medical organizations with medicines and other means, medical devices, immunobiological preparations and disinfectants, as well as donor blood and its components within the framework of the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation, compulsory medical insurance of the non-working population, the provision of specialized (sanitary and aviation) with bark of medical care; development and approval of territorial programs of state guarantees for the provision of free medical care to citizens of the Russian Federation, including territorial programs of compulsory medical insurance; establishing the order and volume of social support measures provided to certain groups of the population in the provision of medical and social assistance and drug provision.
Thus, the establishment of the order and volume of social support measures (in the old terminology - benefits) provided to individual groups of the population in the provision of medical and social assistance and drug provision for current legislation now it is the authority of the constituent entities of the Russian Federation. As a result, from 2005 the regions will have to finance all their obligations, including those for preferential payments. Having strictly delineated the powers in matters of social support with the subjects of the Federation, the federal center assigned the responsibility for possible social problems to the regions.
The powers to issue permits for the use of new methods of prevention, diagnosis and treatment, new medical technologies, licensing of medical and pharmaceutical activities in the territories of the constituent entities of the Russian Federation have been removed from the powers of state authorities of the constituent entities of the Russian Federation.
Part 2 of the article on the transfer of powers of the state authorities of the constituent entities of the Russian Federation in matters of health protection to the state authorities of the Russian Federation was declared invalid.
The jurisdiction of local government bodies (Art. 8), in accordance with the amendments, includes control over compliance with legislation in the field of public health protection; protection of human and civil rights and freedoms in the field of health protection; formation of governing bodies of the municipal health care system; development of institutions of the municipal health care system, determination of the nature and scope of their activities; creating conditions for the development of a private health care system; organization of primary health care in outpatient polyclinic, inpatient polyclinic and hospital institutions, including the provision of these medical organizations with drugs and other drugs, medical products, immunobiological preparations and disinfectants, as well as donor blood and its components, medical care for women in the period of pregnancy, during and after childbirth and emergency medical care (with the exception of air ambulance), ensuring its availability, monitoring compliance with standards of medical care, providing citizens with medicines and medical products in the jurisdictional territory; environmental protection and environmental safety.
It should be noted that the organization and financing of specialized medical care in municipal healthcare organizations did not fall under the authority of the state authorities of the constituent entities of the Russian Federation, or the authority of local self-government bodies.
A number of changes concern the organizational aspects of healthcare activities in the Russian Federation.
In accordance with the new law, the state healthcare system (Article 12) includes federal executive authorities in the field of healthcare, executive authorities of the constituent entities of the Russian Federation in the field of healthcare, Russian academy medical sciences, which, within their competence, plan and implement measures to protect the health of citizens.
The state health care system also includes those in state property and subordinate to the governing bodies of the state health care system, medical and preventive and research institutions, educational institutions, pharmaceutical enterprises and organizations, pharmacies, sanitary and preventive institutions, territorial bodies established in accordance with the established procedure for the implementation of sanitary and epidemiological supervision, forensic medical examination institutions, logistics services, enterprises for the production of medicines and medical equipment and other enterprises, institutions and organizations.
The state health care system includes medical organizations, including medical institutions, pharmaceutical enterprises and organizations, pharmacies created by federal executive bodies in the field of health care, other federal executive bodies and executive bodies of the constituent entities of the Russian Federation.
Art. 13. Municipal health care system - set out in the following edition.
The municipal health care system can include municipal health authorities, as well as municipal-owned medical, pharmaceutical and pharmacy organizations that are legal entities.
Municipal health authorities are responsible within the limits of their competence.
Financial support for the activities of organizations of the municipal health care system is an expenditure obligation of the municipality.
The provision of medical care in organizations of the municipal health care system can be financed from the funds of compulsory medical insurance and other sources in accordance with the legislation of the Russian Federation.
Art. 14. Private health care system - set out as follows.
The private health care system includes medical and prophylactic and pharmaceutical institutions, the property of which is in private ownership, as well as persons engaged in private medical practice and private pharmaceutical activities.
The private health care system includes medical and other organizations created and funded by legal entities and individuals.
A number of changes concern the rights of citizens in the field of health care.
Part of Art. 20, according to which citizens had the right in case of illness to 3 days of unpaid leave during the year without presenting a medical document. This part came into conflict with the Labor Code of the Russian Federation.
Part 5 of Art. 23. The rights of pregnant women and mothers are set out as follows.
"The procedure for ensuring adequate nutrition for pregnant women, nursing mothers, as well as children under the age of 3, including through special food outlets and shops at the conclusion of doctors, is established by the legislation of the constituent entities of the Russian Federation." Thus, the provision on state guarantees for the provision of adequate nutrition to pregnant women, lactating mothers and children under 3 years of age has been excluded.
In Art. 24. The rights of minors - it is determined that dispensary observation and treatment in children's and adolescent services is carried out in the manner established by the federal executive body in the field of health care, and on conditions determined by the state authorities of the constituent entities of the Russian Federation. The right to medical and social assistance and food on preferential terms is excluded. Responsibility for exercising the right to free medical advice in determining professional suitability has been transferred to the constituent entity of the Russian Federation (minors have the right to "free medical consultation when determining professional suitability in the manner and under the conditions established by the state authorities of the constituent entities of the Russian Federation). Minors with physical or mental disabilities. at the request of parents or persons replacing them, they can be held in social protection institutions in the manner and on conditions established by the state authorities of the constituent entities of the Russian Federation (instead of "at the expense of the budgets of all levels") ". Thus, the federal bodies of state power have no powers to exercise the rights of minors. All responsibility for the realization of the rights of minors lies with the constituent entity of the Russian Federation and depends on the availability of money in the budget of this constituent entity of the Russian Federation.
The right to receive medical care in the institutions of the municipal health care system is excluded from the rights of military personnel (Article 25), which will lead to an even greater problem in the provision of medical care to this category of citizens.
Recognized as invalidated by Art. 26. The rights of elderly citizens; Art. 27. The rights of persons with disabilities; Art. 28. The rights of citizens in emergency situations and in ecologically unfavorable areas.
It is assumed that the rights of these groups of the population should be enshrined in special laws.
Changes have been made to section VIII... Guarantees for the implementation of medical and social assistance to citizens.
Art. 38. Primary health care - is set out as follows.
Primary health care is a basic, affordable and free type of medical care for every citizen and includes the treatment of the most common diseases, as well as injuries, poisoning and other emergency conditions; medical prevention of major diseases; sanitary and hygienic education, other activities related to the provision of health care to citizens at the place of residence.
Primary health care is provided by the institutions of the municipal health care system. Institutions of public and private health systems can also participate in the provision of primary health care on the basis of contracts with medical insurance organizations.
The volume and procedure for the provision of primary health care is established by legislation in the field of public health protection.
Financial provision of measures for the provision of primary health care in outpatient clinics, inpatient polyclinic and hospital institutions, medical care for women during pregnancy, during and after childbirth in accordance with these Fundamentals is an expenditure obligation of the municipality.
The provision of primary health care can also be financed from compulsory health insurance funds and other sources in accordance with the legislation of the Russian Federation.
Art. 39. Ambulance - set out as follows.
Emergency medical care is provided to citizens in conditions requiring urgent medical intervention (in case of accidents, injuries, poisoning and other conditions and diseases), it is carried out immediately by medical and preventive institutions, regardless of territorial, departmental subordination and forms of ownership, by medical workers, as well as by persons obliged to provide it in the form of first aid by law or by a special rule.
Emergency medical care is provided by emergency medical institutions and units of the state or municipal health care system in accordance with the procedure established by the federal executive body in charge of legal regulation in the field of health care. Emergency medical care for citizens of the Russian Federation and other persons on its territory is provided free of charge.
The financial support of measures for the provision of specialized (sanitary and aviation) emergency medical care in accordance with these Fundamentals is an expenditure obligation of the constituent entities of the Russian Federation.
Financial support of measures for the provision of emergency medical care (with the exception of sanitary and aviation) to citizens of the Russian Federation and other persons located on its territory, in accordance with these Fundamentals, is an expenditure obligation of the municipality.
The right to free ambulance medical care was excluded in the draft law of the Government of the Russian Federation, and it was with great difficulty that it was defended and preserved.
Art. 40. Specialized medical care - is set out in the following edition.
Specialized medical care is provided to citizens for diseases requiring special diagnostic methods, treatment and the use of complex medical technologies.
Specialized medical care is provided by specialist doctors in medical institutions that have received a license for the specified type of activity.
The types and standards of specialized medical care provided in health care institutions are established by the federal executive body in charge of legal regulation in the field of health care.
Financial support of measures for the provision of specialized medical care in dermatovenerologic, anti-tuberculosis, narcological, oncological dispensaries and other specialized medical organizations (except for federal specialized medical organizations, the list of which is approved by the Government of the Russian Federation) is an expenditure obligation of the constituent entities of the Russian Federation.
The financial support of measures for the provision of specialized medical care provided by federal specialized medical organizations, the list of which is approved by the Government of the Russian Federation, in accordance with these Fundamentals, is an expenditure obligation of the Russian Federation.
Within the meaning of the article, specialized medical care is provided only in institutions of the state health care system (federal specialized medical organizations or specialized medical organizations of the constituent entities of the Federation), which is incorrect. Specialized medical care is also provided in municipal health organizations (both outpatient and inpatient). Accordingly, the law does not contain a clause on the financial support of measures for the provision of specialized medical care in municipal health care organizations.
Thus, primary health care will be provided only at the level of the municipality, and specialized, including in municipal health care organizations, if any (with the exception of federal specialized medical organizations, the list of which is approved by the Government of the Russian Federation), in accordance with by these Fundamentals must be organized and financed by the subject of the Federation. This corresponds to the principle of delineation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local government bodies, however, it will create difficulties in practical health care in the organization and financing of specialized medical care in municipal health care organizations.
Art. 41 is devoted to medical and social assistance to citizens suffering from socially significant diseases. In accordance with the new Fundamentals, measures of social support in the provision of medical and social assistance and drug provision to these citizens are established not at the federal level, but by the state authorities of the constituent entities of the Russian Federation. Financial support of measures for the provision of medical and social assistance to these citizens is an expenditure obligation of the constituent entities of the Russian Federation.
The question involuntarily arises: are there socially significant diseases in a particular region, and the state as a whole is not responsible for diseases that have arisen for social reasons? In addition, with different financial capabilities of the constituent entities of the Federation, a patient with the same disease will have different opportunities when receiving medical and social assistance in different territories.
Art. 42 is devoted to medical and social assistance to citizens suffering from diseases that pose a danger to others. In accordance with the new Fundamentals, the word "free" has been removed when providing medical and social assistance to these citizens. Medical and social assistance to citizens suffering from diseases that pose a danger to others, in accordance with the changes made, is provided only in institutions of the state health care system intended for this purpose (municipal health organizations are excluded) within the framework of the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation. Measures of social support in the provision of medical and social assistance and drug provision to these citizens are established not at the federal level, but by the state authorities of the constituent entities of the Russian Federation. Financial support of measures for the provision of medical and social assistance to citizens suffering from diseases that pose a danger to others is an expenditure obligation of the constituent entities of the Russian Federation.
In addition, medical and social assistance to citizens suffering from diseases that pose a danger to others cannot be provided only within the framework of the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation, because the territorial programs developed in accordance with the federal program do not take into account types and volumes of medical care in epidemic conditions and, accordingly, are not funded for this case.
In connection with the changed social policy, Art. 50. Medical and social expertise. This article is presented in the following edition.
Medical and social expertise is carried out by federal institutions of medical and social expertise in the manner prescribed by the legislation of the Russian Federation.
A citizen or his legal representative has the right to invite, at his request, any specialist with his consent to participate in the medical and social examination.
Section X. Rights and social support of medical and pharmaceutical workers.
In Art. 56. The right to engage in private medical practice - the part defining the powers of the local administration to issue a permit to engage in private medical practice in the jurisdictional territory has been declared invalid. Private medical practice is carried out on the basis of a license; the establishment of the procedure for licensing medical activities falls under the authority of federal government bodies.
Control over the quality of medical care is carried out by the federal executive body, whose competence includes the implementation of state control and supervision in the field of health care, unless otherwise provided by federal law.
Thus, legislatively strengthened control over the activities of the private health care system by the federal executive body. The question arises of how the Ministry of Health and Social Development of the Russian Federation will be able to organizationally carry out this control in all regions of the vast country.
Art. 59. General practitioner (family doctor) - stated as follows.
General practitioner (family doctor) is a doctor who has undergone special multidisciplinary training in the provision of primary health care to family members, regardless of their gender and age.
The procedure for carrying out the activities of a general practitioner (family doctor) is established by the federal executive body in the field of health care, executive bodies of the constituent entities of the Russian Federation.
Substantial changes have been made to Art. 63. Social support and legal protection of medical and pharmaceutical workers.
The right to priority receipt of residential premises, the installation of a telephone, the provision of places for their children in preschool and sanatorium-resort institutions, the purchase on preferential terms of vehicles used to perform professional duties with a traveling nature of work, and other benefits provided by law are excluded. The right of doctors, pharmacists, workers with secondary medical and pharmaceutical education of the state and municipal health care systems, working and living in rural areas and urban-type settlements, as well as their family members living with them, to the free provision of apartments with heating and lighting in accordance with the current legislation is excluded. legislation.
These rights, despite their legislative consolidation, were not implemented.
In this case, there is a clear tendency to build a legal state based on the rule of law. In the laws adopted during the period of socialism and post-socialism, they did not skimp on rights, but some of the rights did not have mechanisms for implementation. This did not seem so important, since there was no obligation to enforce the laws. State administrative mechanisms worked both to protect the citizen and to suppress him. With the establishment of the rule of law, the role of law in society has increased, citizens have learned to defend their rights in court, enshrined in the law. Taking this into account, the modern legislator follows the path of limiting rights and the compliance of legislation with the existing state of affairs, that is, the possibilities of exercising the right.
This article is supplemented by the following parts.
Measures of social support for medical and pharmaceutical workers of federal specialized health organizations are established by the Government of the Russian Federation.
Measures of social support for medical and pharmaceutical workers of healthcare organizations under the jurisdiction of the constituent entities of the Russian Federation are established by the state authorities of the constituent entities of the Russian Federation.
Measures of social support for medical and pharmaceutical workers of municipal health organizations are established by local government bodies.
This corresponds to the principle of differentiation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local government bodies, however, the division of medical workers in matters of social support by levels - federal, regional and municipal - will lead to inequality of citizens' rights on the territory of the state.
Art. 64. Compulsory insurance of medical, pharmaceutical and other employees of the state and municipal health care systems, whose work is associated with a threat to their life and health - is set out in the following edition.
For medical, pharmaceutical and other employees of the state and municipal health care systems, whose work is associated with a threat to their life and health, compulsory insurance is established in accordance with the list of positions, the occupation of which is associated with a threat to the life and health of employees, approved by the Government of the Russian Federation.
The amount and procedure for compulsory insurance for medical, pharmaceutical and other employees of federal specialized healthcare organizations whose work is associated with a threat to their life and health are established by the Government of the Russian Federation. The amount and procedure for compulsory insurance for medical, pharmaceutical and other health care workers under the jurisdiction of the constituent entity of the Russian Federation, whose work is associated with a threat to their life and health, are established by the state authorities of the constituent entity of the Russian Federation.
The amount and procedure for compulsory insurance for medical, pharmaceutical and other employees of municipal health organizations, whose work is associated with a threat to their life and health, are established by local government bodies.
In the event of the death of employees of the state and municipal health care systems in the performance of their labor duties or professional duty during the provision of medical care or scientific research the families of the victims are paid a one-time cash benefit.
The amount of a one-time cash benefit in the event of the death of employees of federal specialized healthcare organizations is established by the Government of the Russian Federation.
The amount of a lump-sum cash benefit in the event of the death of workers in health care organizations under the jurisdiction of a constituent entity of the Russian Federation is established by the state authorities of the constituent entity of the Russian Federation.
The amount of a one-time cash benefit in the event of the death of employees of municipal health care organizations is established by local government bodies.
In accordance with Art. 15 of the new law amended the Law of the Russian Federation dated 02.07.92 No. 3185-1 "On psychiatric care and guarantees of citizens' rights during its provision".
In Art. 16 the organization of the provision of psychiatric care is entrusted to federal specialized medical institutions, the list of which is approved by the Government of the Russian Federation, and specialized medical institutions of the constituent entities of the Russian Federation. Thus, local governments are not involved in providing the population with psychiatric care.
The solution of issues of social support and social services for persons suffering from mental disorders in difficult life situations is carried out by the state authorities of the constituent entities of the Russian Federation.
Art. 17. Financing of mental health care - set out as follows.
Financial support of psychiatric care provided to the population in federal specialized medical institutions, the list of which is approved by the Government of the Russian Federation, is an expenditure obligation of the Russian Federation.
Financial support for the provision of psychiatric care to the population (with the exception of psychiatric care provided in federal specialized medical institutions, the list of which is approved by the Government of the Russian Federation), as well as social support and social services for persons suffering from mental disorders in difficult life situations, is an expenditure obligation of the subjects Russian Federation.
With a lack of financial resources, the constituent entities of the Federation are unlikely to be interested in the development of a psychiatric service, this category of patients in a number of regions may find themselves without specialized medical care.
Art. 22. The guarantees for psychiatrists, other specialists, medical and other personnel involved in the provision of psychiatric care are set out in the following edition.
1) Psychiatrists, other specialists, medical and other personnel involved in the provision of psychiatric care are entitled to reduced working hours, additional leave for work in especially hazardous to health and difficult working conditions in accordance with the legislation of the Russian Federation.
2) Psychiatrists, other specialists, medical and other personnel involved in the provision of psychiatric care are subject to compulsory insurance in case of harm to their health or death in the performance of official duties in the manner prescribed by the legislation of the Russian Federation; obligatory social insurance from industrial accidents and occupational diseases in the manner prescribed by the legislation of the Russian Federation.
The question arises, what is the difference between working with patients with mental illness in federal health care institutions from working with patients with mental illness in medical institutions of the constituent entities of the Russian Federation, if the personnel working with them will have different allowances?
In Art. 45, the procedure for monitoring mental health care activities has been changed. Control over the activities of federal psychiatric and neuropsychiatric institutions is carried out by authorized federal executive bodies, control over the activities of psychiatric and neuropsychiatric institutions under the jurisdiction of a constituent entity of the Russian Federation is exercised by the authorized federal executive body and executive bodies of the constituent entities of the Russian Federation.
Control over the activities of federal psychiatric and neuropsychiatric institutions is carried out in the manner determined by the Government of the Russian Federation.
In accordance with Art. 32 of the new law amended the Law of the Russian Federation dated 09.06.93 No. 5142-1 "On the donation of blood and its components".
In Art. 1 removed the upper age limit. A donor of blood and its components can be any capable citizen over the age of 18 (in old edition- up to 60 years old), passed a medical examination.
Excluded article on federal programs development of blood donation. There will no longer be such programs that are legally binding on the state.
Art. 4. Provision of measures for the development, organization and promotion of donation of blood and its components - set out in the following edition.
Financial support of measures for the development, organization and promotion of donation of blood and its components, carried out in order to ensure specialized medical care provided by federal health organizations, is an expenditure obligation of the Russian Federation.
Financial support of measures for the development, organization and promotion of the donation of blood and its components, carried out in order to provide specialized medical care (with the exception of that provided by federal health organizations), specialized (sanitary and aviation) emergency medical care, is an expenditure obligation of the constituent entities of the Russian Federation.
Financial provision of measures for the development, organization and promotion of the donation of blood and its components, carried out in order to ensure the provision of primary health care, medical care to women during pregnancy, during and after childbirth and emergency medical care (except for air ambulance), is an expenditure obligation of municipalities.
The implementation of measures for the development, organization and promotion of the donation of blood and its components is carried out on the basis of the creation of a unified information base in the manner established by the Government of the Russian Federation.
Art. 11 defines social support measures for persons awarded with the "Honorary Donor of Russia" badge. Financial support of expenses related to the implementation of the rights of honorary donors remains an expenditure obligation of the Russian Federation, that is, with great difficulty, but it was possible to defend the financing of social support measures for honorary donors from the federal budget.
In accordance with Art. 48 of the new law, amendments have been made to the Federal Law of March 30, 1995 No. 38-FZ "On the prevention of the spread in the Russian Federation of a disease caused by the human immunodeficiency virus (HIV)".
In Art. 4. State guarantees - the following changes have been made.
The state guarantees the provision of medical care to HIV-infected citizens of the Russian Federation in accordance with the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation, as well as the provision of free medicines for the treatment of HIV infection on an outpatient basis in federal specialized medical institutions in accordance with the procedure established by the Government of the Russian Federation. Federation, and in health care institutions under the jurisdiction of the constituent entity of the Russian Federation, in the manner established by the state authorities of the constituent entities of the Russian Federation.
Art. 6. Financial support of activities to prevent the spread of HIV infection - set out in the following version.
Financial support of measures to prevent the spread of HIV infection, carried out by federal specialized medical institutions and other organizations of federal subordination, refers to the expenditure obligations of the Russian Federation.
Financial support of measures to prevent the spread of HIV infection, carried out by health care institutions under the jurisdiction of the constituent entities of the Russian Federation, refers to the expenditure obligations of the constituent entities of the Russian Federation.
Art. 21. State lump sum benefits, invalidated. Thus, the right of employees of enterprises, institutions and healthcare organizations, whose work is related to the diagnosis, treatment of HIV-infected patients and materials containing HIV, to receive state lump-sum benefits in case of contracting HIV while on duty.
Art. 22. Labor guarantees - set out in the following edition.
1. Employees of enterprises, institutions and organizations of the state health care system carrying out diagnostics and treatment of HIV-infected, as well as persons whose work is associated with materials containing the human immunodeficiency virus, have the right to reduced working hours, additional leave for work in especially dangerous for health and difficult working conditions in accordance with the legislation of the Russian Federation.
The procedure for the provision of these guarantees and the establishment of the amount of bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of federal healthcare institutions is determined by the Government of the Russian Federation.
The procedure for the provision of these guarantees and the establishment of the amount of increments to official salaries for work in especially hazardous to health and difficult working conditions for workers of health care institutions of the constituent entities of the Russian Federation is determined by the executive authorities of the constituent entities of the Russian Federation.
2. Employees of enterprises, institutions and organizations of the state health care system, carrying out diagnostics and treatment of HIV-infected, as well as persons whose work is related to materials containing the human immunodeficiency virus, are subject to compulsory insurance in case of harm to their health or death in the line of duty in the manner prescribed by the legislation of the Russian Federation; compulsory social insurance against industrial accidents and occupational diseases in the manner prescribed by the legislation of the Russian Federation.
The same question arises: what is the difference between working with HIV-infected blood in federal healthcare institutions from working with HIV-infected blood in medical institutions of the constituent entities of the Russian Federation, if the personnel have different allowances?
In accordance with Art. 135 of the new law, amendments have been made to the Federal Law of 18.06.01 No. 77-FZ "On the Prevention of the Spread of Tuberculosis in the Russian Federation".
In Chapter II, the powers of local self-government bodies are removed from the powers in the field of preventing the spread of tuberculosis, thus all powers in this area are distributed between the Russian Federation and the constituent entities of the Russian Federation.
The powers of the Russian Federation to ensure economic, social and legal conditions to prevent the spread of tuberculosis have been removed from the powers of the Russian Federation.
Art. 5. The powers of the constituent entities of the Russian Federation in the field of preventing the spread of tuberculosis are set out as follows.
The constituent entities of the Russian Federation shall organize the prevention of the spread of tuberculosis, including anti-tuberculosis care for patients with tuberculosis in anti-tuberculosis dispensaries, other specialized medical anti-tuberculosis organizations and other healthcare institutions of the constituent entities of the Russian Federation.
It is known that tuberculosis is a socially significant disease, and only the state as a whole can solve the problem of socially significant diseases, influencing the economic, social and legal living conditions of people,
State refusal to influence social conditions life of people, the redistribution of responsibility for measures of social support and financial support of measures for the provision of medical and social assistance to citizens suffering from socially significant diseases to the state authorities of the constituent entities of the Russian Federation will worsen the situation with these diseases. And the point is not only that the subjects do not have enough money in the budgets to treat such a pathology. An individual subject of the Federation, no matter how good everything is in this subject (even an oil-producing, rich region that is a donor of the federal budget, capable of providing social support to the inhabitants of its region), cannot influence the situation in the country as a whole. No one can restrict the constitutional right of a citizen to free movement, choice of place of stay and residence (Article 27 of the Constitution of the Russian Federation), therefore, patients with socially significant diseases can move to regions with a more funded system of social support. The influx of socially disadvantaged citizens into the regions, namely, they most often have socially significant diseases, is unlikely to have a positive effect on the development of these regions.
In addition, the decrease in the responsibility of the state for the social processes taking place in this state is a blow to the authority of the state as a whole, undermines faith in the social orientation of state policy.
The provision of anti-tuberculosis care to citizens in accordance with the adopted amendments is carried out not on the basis of the principle of gratuitousness (in the old edition), but in the volumes envisaged by the Program of state guarantees for the provision of free medical care to citizens of the Russian Federation. The program of state guarantees for the provision of free medical care to citizens of the Russian Federation is implemented in the territories through territorial programs, which are funded in different territories in different ways. Thus, with insufficient financing of the territorial program of state guarantees for the provision of free medical care to citizens of a particular constituent entity of the Russian Federation, there may be restrictions on the required volume of medical care for patients with tuberculosis. This will lead to a worsening of the already unfavorable epidemic situation for tuberculosis in certain regions and in the country as a whole.
Exclusion from the rights of persons under observation in connection with tuberculosis and patients with tuberculosis of the right to free travel on transport common use Urban and suburban communication, when called or sent for consultations to medical anti-tuberculosis organizations, is unlikely to help improve the epidemic situation, especially in rural areas.
The rights of persons under surveillance for tuberculosis and patients with tuberculosis to be provided with free medicines for the treatment of tuberculosis are set out as follows.
Persons under dispensary supervision in connection with tuberculosis and patients with tuberculosis are provided with free medicines for the treatment of tuberculosis on an outpatient basis in federal specialized medical institutions in accordance with the procedure established by the Government of the Russian Federation, and in health care institutions under the jurisdiction of the constituent entities of the Russian Federation - in the procedure established by the state authorities of the constituent entities of the Russian Federation.
Patients with infectious forms of tuberculosis living in apartments in which, based on the occupied living space and family composition, it is impossible to allocate a separate room for a patient with an infectious form of tuberculosis, communal apartments, dormitories, as well as families with a child sick with an infectious form of tuberculosis, are provided outside separate queues Living spaces taking into account their right to additional living space in accordance with the legislation of the constituent entities of the Russian Federation.
Art. 15. Social support of medical, veterinary and other workers directly involved in the provision of anti-tuberculosis care is set out in the following version.
1. Medical, veterinary and other workers directly involved in the provision of anti-tuberculosis care, as well as employees of organizations for the production and storage of livestock products serving farm animals with tuberculosis, have the right to a reduced working time, additional leave for work in especially hazardous to health and difficult working conditions in accordance with the legislation of the Russian Federation.
The procedure for the provision of these guarantees and the establishment of the amount of bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of federal healthcare institutions is determined by the Government of the Russian Federation.
The procedure for the provision of these guarantees and the establishment of the amount of increments to official salaries for work in especially hazardous to health and difficult working conditions for workers of health care institutions of the constituent entities of the Russian Federation is determined by the executive authorities of the constituent entities of the Russian Federation.
2. Medical, veterinary and other workers directly involved in the provision of anti-tuberculosis care, as well as employees of organizations for the production and storage of livestock products serving farm animals with tuberculosis, are subject to compulsory insurance in case of harm to their health or death in the performance of official duties in accordance with established by the legislation of the Russian Federation; compulsory social insurance against industrial accidents and occupational diseases in the manner prescribed by the legislation of the Russian Federation.
The same question: what is the difference between working with tuberculosis in federal healthcare institutions from working with tuberculosis in medical institutions of the constituent entities of the Russian Federation?
These are the main changes made to Russian legislation on health care in connection with the adoption of the new law. Also, serious changes have been made to federal laws in the field of public health, directly related to the legislation on health care: "On immunization of infectious diseases" (dated 17.09.98 No. 157-FZ); "On the sanitary and epidemiological well-being of the population" (dated March 30, 1999, No. 52-FZ); "On Medicines" (dated 22.06.98 No. 86-FZ); "On the quality and safety of food products" (dated 02.01.2000 No. 29-FZ); "On specially protected natural areas"(dated 14.03.95 No. 33-FZ).
In general, it should be noted that although the delineation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local government bodies, of course, had the goal of changing the system of interbudgetary financial relations within the Federation, including health financing, the law did not simplify, but complicated the organization and inter-budgetary relations for the financial provision of medical care. For example, there will be difficulties with the implementation of the right of citizens to medical care in the provision of emergency, primary health care, specialized medical care due to the lack of funds in the relevant budgets. Ensuring state guarantees of the right of citizens to health protection and medical care (Article 41 of the Constitution of the Russian Federation) will still require the allocation of subventions to regional and local budgets in the amount necessary for the implementation of territorial programs of state guarantees for the provision of free medical care to citizens in the main types and volumes of medical care stipulated in the federal program.
2.2 Topical issues of legal regulation of the economic aspects of the activities of health care institutions
In modern conditions, not only the medical, but also the economic side of the activities of health care institutions are largely determined by the current regulatory framework.
The transformation of medical institutions from ordinary consumers of budgetary resources into independent economic entities, the introduction of compulsory and voluntary medical insurance, the development of entrepreneurial activity and other innovations required a significant reform of the methods of economic activity. Meanwhile, there are serious problems in the legal regulation of the economic aspects of the activity of medical institutions, which can be grouped as follows: the lack of legal regulation of certain aspects of the activity of medical institutions; insufficient legal framework in certain areas of activity; inconsistency of legal regulation; the presence of legal norms with a controversial interpretation; inconsistency of legal regulation with the tasks of health care development or the interests of the state; insufficient legal literacy of heads of medical institutions; implementation problems legal rights medical institutions in economic matters.
Let's consider these groups of problems in more detail.
Lack of legal regulation of certain aspects of the activities of medical institutions. The dynamism of the processes taking place in society and, in particular, in health care, leads to the fact that legal regulation does not keep pace with the pace of reforms. Therefore, currently there is no legal regulation of a number of economic issues of the activities of health care institutions. This applies, for example, to some aspects of the activities of medical institutions related to the use of state (municipal) property in the implementation of entrepreneurial activities by budgetary medical institutions. In particular, this applies to the use of buildings (premises). Budgetary medical institutions within the framework of their main activity use buildings and structures free of charge. Accordingly, there is no methodological or regulatory framework for including the cost of these resources (depreciation) in the prices for paid services. However, prices for paid services are guided by the market level, which is formed primarily by commercial non-state medical institutions and includes all types of costs, including depreciation of buildings. In this situation, budgetary institutions, providing paid services at market prices, receive excess profits, the real basis of which is the unreimbursed cost of buildings (in the form of depreciation or rent).
Currently, there is no necessary legal regulation and a number of issues related to guarantees for the provision of free medical care. Everyone is well aware that the types and volumes of medical care envisaged by the programs of state guarantees for the provision of free medical care to citizens exceed the financial capabilities of the budget and the means of compulsory medical insurance (MHI). It is no coincidence that even in the Address of the President of the Russian Federation to the Federal Assembly of the Russian Federation in 2001, it was noted that “... in the absolute majority of regions this program is not provided with state funds. The deficit of funds under this program is 30-40 percent of the need, and it is covered .. . the forced expenses of patients to pay for drugs and medical services. " Meanwhile, medical institutions cannot fail to fulfill the program of state guarantees, and the officially established mechanism for compensating for the deficiency financial security there is no territorial program of state guarantees at the expense of the budget or funds of the population. There is also no normative regulation of the situation of exceeding within the framework of a particular medical institution or the entire territory of the volume of free assistance provided for by the program. It is clear that an institution (doctor) cannot refuse to provide medical care to a patient on the grounds that the institution has already exceeded the planned volumes approved by the program. This would violate a number of laws, including the Penal Code. But can the institution (at least theoretically) offer the population to pay for medical services provided in excess of the program? Neither the decree of the Government of the Russian Federation of 11.09.98 No. 1096 "On the approval of the program of state guarantees for providing citizens of the Russian Federation with free medical care", nor other normative acts devoted to this problem, give an answer to this question.
Meanwhile, in many countries (for example, in Kyrgyzstan) various forms of partial participation of the population in financing the provision of medical care are used. These are the so-called copayments. There is currently no legal regulation of this form of compensation for the lack of budgetary funding or MHI funds.
Lack of legal framework in certain areas of activity. Ten years of experience in the work of medical institutions in the compulsory medical insurance system revealed the need to improve legislation in this area. Let's give an example. The current legislation does not provide a clear definition of what level of budget funds should be used to carry out compulsory medical insurance (who exactly should be the insured) of the non-working population. In Art. 2 of the Law "On Health Insurance of Citizens in the Russian Federation" states that the number of insurers of the non-working population includes both the state authorities of the constituent entities of the Federation and the local administration. Therefore, in different regions this problem is solved in different ways: in some regions, insurance of the non-working population is carried out at the expense of the budget of the constituent entity of the Federation, in others - at the expense of municipal (district) budgets. This and many other problems are intended to be resolved by the law "On compulsory health insurance" that is being drafted now.
The legal regulation of relations in the field of private medical activity cannot be considered sufficient either. Medical activity is special kind activities with high risk for life and health. In the private health sector, in contrast to the state and municipal, there are no governing bodies and structures that organize this activity, exercise leadership and control. In order to fill these gaps, the State Duma Health and Sports Committee has prepared a draft federal law "On the regulation of private medical activity."
The increase in the volume of paid services provided by state and municipal medical institutions also revealed a number of problems associated with the procedure for their provision. In some cases, there is an uncontrolled development of the entrepreneurial activity of medical institutions, which is detrimental to the interests of the state and the population; in other cases, higher authorities put obstacles in the way of reasonable directions for the provision of paid services. This is primarily due to poor development regulatory framework provision of paid services in healthcare. At the same time, there is a fairly clear legal basis entrepreneurial activity of non-profit organizations (which include budgetary medical institutions), taxation, etc., recorded in a number of adopted laws, decrees of the Government of the Russian Federation and other regulatory legal acts... Therefore, the insufficient development of the regulatory framework is manifested mainly in the absence of a clear mechanism for regulating the procedure for the provision of paid medical services, enshrined in the departmental regulations of the Ministry of Health of the Russian Federation (orders, instructions, etc.). Departmental regulations are intended to provide an interpretation of legislative and other legal acts in relation to medical institutions, taking into account the specifics of the industry. Meanwhile, even the main order of the Ministry of Health of the Russian Federation regulating the procedure for the provision of paid services (dated March 29, 1996, No. 109 "On the rules for the provision of paid medical services to the population"), only duplicated the Resolution of the Government of the Russian Federation of January 13, 1996 No. 27 "On approving the rules for the provision of paid medical services. to the population by medical institutions ", without introducing anything new. It is obvious that these rules do not cover the entire list of issues that arise in the provision of paid services. Not filling all the gaps and other few orders of the Ministry of Health of the Russian Federation, affecting the provision of paid services (dated 03/20/92 No. public organizations, institutions, enterprises and other business entities with any form of ownership, as well as personal funds of citizens "; dated 06.08.96 No. 312" On the organization of the work of dental institutions in the new economic conditions of management ", etc.).
An example of the inconsistency of legal regulation is the situation with the taxation of the activities of health care institutions in the CHI system. As you know, state extra-budgetary funds (which include the CHI fund) are included in the budgetary system of the Russian Federation (Article 6 of the Budget Code of the Russian Federation). Therefore, in accordance with Art. 251 of the Tax Code of the Russian Federation, the amount of financing from the budgets of state extrabudgetary funds refer to earmarked income, that is, income not taken into account in determining tax base income tax. However, in practice, medical institutions usually receive these funds not directly from CHI funds in the form of direct financing, but through medical insurance organizations under civil law contracts in accordance with the volume of services provided. In many cases tax authorities refuse to recognize these incomes as earmarked receipts and insist on their inclusion in the tax base.
Unfortunately, in many respects, changes in tax legislation also have an adverse effect on the filling of budgets at the regional and local levels and, accordingly, on the financial possibilities of supporting health care. Thus, as a result of tax changes, the regions in recent years have lost a significant part of the income that went to the federal budget. At the same time, the main financial burden for providing citizens with free medical care remains with the regions - local budgets and the budgets of the constituent entities of the Federation. Moreover, the state policy aimed at easing the tax burden, while positive in itself, in many cases turns out to be unprofitable for regional budgets (and, accordingly, for health care). For example, according to the current legislation, the bulk of the income tax is directed to the budgets of the constituent entities of the Federation, and a decrease tax rate income tax has the greatest impact on regional budgets. As for positive sides reducing the tax burden, they are manifested primarily in stimulating production growth, the logical result of which is an increase in tax revenues from value added tax, which in turn is sent to the federal budget.
Serious contradictions in legal regulation are also revealed by the implementation of the RF law "On health insurance of citizens in the Russian Federation." The lack of legal regulation in the field of compulsory health insurance has already been noted above. Here I would like to draw your attention to the presence of contradictions of the above law with other regulations. Despite the existence of a law establishing uniform principles of health insurance, each constituent entity of the Federation implements its own CHI models, and often directly contradicting the principles laid down in the law (there are no insurance organizations or territorial funds of compulsory medical insurance; executive authorities do not contribute funds for insurance of the non-working population, etc.). This was the result of both the imperfection of the law itself, which is mostly declarative in nature, and the fact that it came into conflict with a number of legislative acts granting broad rights to the subjects of the Federation in regulating financial and social issues in their regions.
The presence of legal norms with a controversial interpretation. Among the legal norms that cause the largest number of disputes on economic issues are the issues of wages and pricing in the provision of paid services by medical institutions. Thus, the current Labor Code of the Russian Federation (Article 135) determines that the establishment wages employees of organizations with mixed financing ( budget financing and income from entrepreneurial activity) is produced in accordance with laws, other regulatory legal acts, collective agreements, agreements, local regulatory acts of organizations. Higher-level healthcare authorities usually interpret this article as follows: collective agreements, agreements, local regulations of medical institutions are valid if they do not contradict current regulations and decisions higher authorities(including the orders of the relevant health management body). Formally, this is the correct interpretation, but it does not take into account differences in funding sources. The fact is that, as can be seen from the previous phrase of the same article of the Labor Code, by the relevant laws and other regulatory legal acts, wages are established only for employees whose activities are financed from the budget. It follows from this that for workers providing paid services, wages are established by collective agreements, agreements, local regulations of organizations, that is, medical institutions independently regulate this issue, especially since in Art. 161 of the Budget Code of the Russian Federation states that "a budgetary institution, when executing estimates of income and expenses, independently in spending funds received from extra-budgetary sources."
Another issue that has a different interpretation is the application of a state (municipal) contract (order) to the services of budgetary medical institutions. As you know, a state or municipal contract can be concluded by a public authority or a local self-government body, a budgetary institution, an authorized body with individuals and legal entities in order to meet state or municipal needs. However, practice shows that the concept of a state (municipal) contract or order is practically not used for the procurement of medical services from the budgetary healthcare institutions themselves, although this is quite consistent with the concept of a contract (order) given in Art. 72 of the Budget Code. Considering that state and municipal contracts should be placed on a competitive basis, this would largely contribute to solving the urgent problem of restructuring the network of medical institutions.
The issue of borrowing by state and municipal budgetary health care institutions from third parties is also controversial. In Art. 118 of the Budget Code of the Russian Federation states that budgetary institutions are not allowed to receive loans from credit institutions and other individuals and legal entities, with the exception of loans from budgets and state extra-budgetary funds. The requirement seems to be logical: after all, in accordance with Art. 120 Civil Code RF, if the medical institution is unable to repay the loan, the owner of the respective property bears subsidiary responsibility for its obligations. However, medical institutions are expanding their business activities, which is difficult to do without using borrowed money... Meanwhile, it is not entirely clear whether the restriction on borrowing, introduced The Budget Code, only the budgetary activities of state (municipal) medical institutions or applies to extrabudgetary activities.
Inconsistency of legal regulation with the tasks of health care development or the interests of the state. In Art. 256 of the Tax Code of the Russian Federation states that property of budgetary organizations is not subject to depreciation, with the exception of property acquired in connection with entrepreneurial activities and used for such activities. This means that if a budgetary medical institution provides paid services using property acquired from the budget or from the compulsory medical insurance funds (and this is a widespread practice), then it cannot attribute the depreciation of this property to costs. As a result, state (municipal) property will be used to provide paid services free of charge. This situation could be considered as a kind of subsidizing the provision of paid services to the population, if not for 2 circumstances. First, these subsidies will also apply to those types of services that, by definition, should be provided only for a fee (service, cosmetology without medical indications, etc.). Secondly, such subsidies destabilize the market for paid (commercial) medical services, since private institutions are deprived of this subsidy and are forced to provide services at a full, higher price. All this leads to the well-known costs associated with the disruption of normal market processes. In our opinion, the problem should be solved in a different way: it is necessary to include in the price of a paid service of depreciation of any used property, but that part of depreciation that is charged on state (municipal) property should be returned to the budget or taken into account as part of budget financing.
The legal regulation of voluntary health insurance does not always meet the interests of society. For example, in Art. 1 of the RF Law "On Medical Insurance of Citizens in the Russian Federation" states that "voluntary medical insurance is carried out on the basis of voluntary medical insurance programs and provides citizens with additional medical and other services in excess of those established by compulsory medical insurance programs." From the content of this article it follows that the voluntary medical insurance program for employees of a highly profitable enterprise, bank, etc. the types of assistance included in the territorial compulsory medical insurance program cannot be present. It turns out that wealthy enterprises or citizens are ready to fully pay for medical care at their own expense, without resorting to compulsory medical insurance services (thereby saving compulsory medical insurance funds to provide free assistance to less wealthy citizens), and the law limits them in this desire. Obviously, an increase in the number of grounds is required to expand the scope of the voluntary health insurance program (for example, if the insured are willing, etc.).
In our opinion, many provisions of the legislation in the field of taxation do not meet the objectives of health care development. In particular, this concerns the introduction of a value added tax on medicines, the spread of sales tax to paid medical services, and the very procedure for taxing the income of medical institutions from the provision of paid services. All this reduces the already meager financial potential of health care, reduces the availability of paid services and medicines for the population.
Insufficient legal literacy of heads of medical institutions. Unfortunately, we have to admit that the legal literacy of the heads of medical institutions leaves much to be desired. Meanwhile, knowledge of the basic normative documents and general legal principles concerning the activities of a medical institution, allows not only to carry out their activities more efficiently, but also in many cases to defend their legal rights. In addition to improving the legal training of students of medical universities and students of advanced training courses, it is necessary to introduce legal advisers to the staff of all medical institutions or conclude contracts for legal services for the activities of medical institutions.
Problems of the implementation of the legal rights of medical institutions in economic matters. Unfortunately, knowledge of legislation is far from sufficient to use it in practice. Medical institutions very often have to deal with situations when they clearly understand the legal side of the problem, but cannot act in accordance with the existing legislation. In particular, this concerns issues of pricing for paid medical services. In accordance with the Decree of the Government of the Russian Federation of 03/07/95 No. 239 "On measures to streamline state regulation of prices (tariffs)" does not provide for state regulation of prices for paid medical services. In order to clarify this issue in the letter of the Ministry of Economy of the Russian Federation dated 03.03.99 No. 7-225 "On prices for paid medical services" it was reported that state regulation of prices (tariffs) does not apply to paid services, the list of which is not provided for by the decree of the Government of the Russian Federation dated 07.03.95 No. 239. Nevertheless, almost everywhere government bodies or health authorities intervene in pricing issues.
Other issues on which medical institutions often experience unreasonable pressure from higher authorities include the level of salaries included in the prices of paid services; use of income received from entrepreneurial activity; remuneration of employees at the expense of income received from the provision of paid services, etc.
Of course, medical institutions can resort to such a form of protection of their legal rights as going to court. However, practice shows that medical institutions rarely use this right, because, having won a lawsuit, the head of the institution may lose his position. The higher authorities have plenty of opportunities for this. The legal insecurity of the head of a medical institution is another serious problem that limits the scope of the legal field in healthcare.
In conclusion, we note that we have touched on only a small part of the issues related to the regulatory framework for reforming the health care economy, but the issues considered indicate the presence of serious problems in this area. It is obvious that the improvement of legal regulation of the economic aspects of the activities of medical institutions should not only be based on the fundamental principles of law, requirements for the protection of the rights and freedoms of citizens, respect for the interests of the state, etc., but also comply with economic laws, contribute to the effective economic activity of healthcare institutions.
In order to improve the legal framework for health protection, including the solution of many economic issues, the Committee for Health Protection and Sports of the State Duma
carries out a lot of work to improve legislation in the field of healthcare. It is expressed not only in making changes to applicable laws and the development of new bills, but also in the systematic formation of the Code of Laws on the Protection of Public Health.
At the same time, it is obvious that most of the problems discussed above cannot be solved only within the framework of legislation in the field of health care, since changes (amendments) are required in a number of legislative acts of a more general plan (Civil, Budget, Tax Codes, etc.). Moreover, big role The executive authorities (the Government of the Russian Federation, the Ministry of Health of the Russian Federation, etc.), as well as the legislative bodies of the constituent entities of the Federation, should play in improving the legal regulation of the economic sphere of health care.
3. Problems of public administration in the field of health care and ways to solve them
3.1 Problems of improving the organization of medical care for the population
The organization of medical care in rural areas has a number of features, among which a small number of the served population living in a fairly large territory can be distinguished; the prevalence of non-working and pensioners among rural residents; the lack of opportunities for the population of the rural area to fully exercise the right to choose a medical institution.
The socio-economic transformations of recent decades have complicated the availability of medical care to the rural population, have not improved the quality and have not raised the level of its organization. Since the beginning of the 1990s, there has been a decrease in resource provision rural health... Weak medical and diagnostic base, low material and technical equipment, low level of development information technologies- this is not a complete list of the current state of rural medical institutions. Along with the aforementioned difficulties, one of the serious problems of practical health care in modern conditions is the low efficiency of using the resource base. The main task of improving the organization of medical care for the rural population is reasonably to reorient the main efforts from the hospital stage to the outpatient one, i.e., restructuring care while improving its quality and reducing costs. Analyzing the real changes that took place at the end of the last century and the beginning of the new century, it can be concluded that the reform processes, which have been sufficiently developed at the theoretical level and reflected in the Concept for the Development of Healthcare and Medical Science in the Russian Federation (1997), are proceeding slowly or almost absent in practice, and the structural effectiveness of the health care system as a whole remains lower than expected. It is necessary to increase interaction and continuity in the activities of all links of the system, priority development outpatient-polyclinic link, redistribution of the volume of activity and resource provision between the structures of hospital, out-of-hospital, medical and social care.
One of the main directions of improving the organization of medical care is the development of primary health care (PHC). In this case, a special role is assigned to the development of the institute of general (family) practice (GP). The World Health Organization, which regularly publishes ratings of health systems in countries of the world, considers the main thing not to be their scientific and material and technical base, but the availability of medical services for the population, which is largely determined by the state of primary health care. A doctor is needed who is able to take over all the first contacts with the population, to promptly seek advice from more qualified, better equipped second-level specialists, and if necessary, send the patient to a hospital. The delay in establishing a GP service has a significant impact on the advancement of overall health care reform. The shift towards outpatient care and the reduction of unjustified volumes of medical care are almost entirely dependent on the development of the GP service, and this does not exclude the development of many hospital-substituting forms of medical care.
The main problems of organizing out-of-hospital care for the rural population according to the principle of general medical practice (GPP) are the imperfection of the regulatory and methodological framework governing the role and place of GPs in the rural health care system, the legal status of GPs, their interaction with other medical institutions, funding mechanisms for GPs; the lack of training standards for the staff of the GP, defining the list of knowledge and practical skills of the staff of the GP; the lack of developed standards for medical and technical support for AFP, which does not allow their adequate provision with medical equipment.
In the conditions of the transition period from the service of district doctors to the GP, it is inappropriate to go by reducing the number of positions of doctors - narrow specialists. The experience of rural municipal health care facilities shows that there are not enough such doctors. Saving money on doctors - narrow specialists and the redistribution of funds in favor of GPs at the moment will lead to a decrease in the availability of specialized free medical care to the population. Today, it is most profitable to introduce ORP in remote sparsely populated areas, in rural areas, as well as in economically favorable regions with a solvent population, for example, in Moscow, as a paid medical activity to serve certain categories of citizens.
Until now, in Western Europe there is a high proportion of single practices (in the Netherlands - 54%, in the UK - 30%), which mainly operate in rural areas with a relatively low population density. In the UK, the GP visits patients at home less intensively than in Russia - in 15-20% of cases (visits to the elderly and people who cannot come for an appointment), and in Russia - in 30-40%, and a significant part of the visits in our country is not justified. Moreover, the reception of GPs in the UK and the Netherlands takes up to 8 minutes on average; a detailed conversation with the patient, in-depth diagnostic studies, detailed records in the outpatient card are not carried out.
The introduction of the GP institute in rural areas of the Chuvash Republic is accompanied by a significant economic effect. Already at the initial stage of implementation in the service area of these specialists, there is a decrease in the level of hospitalization by 5-10%, a decrease in the number of ambulance calls by 5-15%, and the number of referrals to narrow specialists has decreased by 10-15%.
One of the most cost-effective ways to provide medical services at the PHC level is nursing, which can be thought of as a savings reserve for regional and municipal health care. An AFP nurse, if properly trained, can be assigned many of the responsibilities that a physician performs today. This is how nursing staff operate successfully in European countries. The main forms of independent work of OVP nurses are patronage of the patient at home, conducting classes in "schools for patients", and admission to the polyclinic. Medical care provided by a paramedic who has a certificate of a specialist in medical care is characterized by a large amount of treatment and prophylactic work with sufficient quality of first-aid medical care. Important medical traditions are preserved - the provision of assistance by a paramedic at home to adults and children, including outside working hours. All this increases the role of the paramedic in the ORP system. The outpatient link can be significantly strengthened due to the reinforcement of paramedical personnel at the rate of a paramedic and two nurses for a population served from 2,800 to 3,200 people.
Before today no real reform of primary health care took place. The overwhelming majority of outpatient clinics continue to provide primary medical care by the local therapist and narrow specialists. The analysis of the implementation of the sectoral program "General medical (family) practice" showed the need to use a systematic approach in improving the regulatory, socio-economic, financial, material, technical, organizational, methodological and managerial mechanisms that determine the peculiarities of the organization and functioning of the GP service in the structure of the primary health care.
As part of restructuring and improving the efficiency of healthcare important aspect is the development of hospital-substituting forms of medical care. So, at present, the proportion of daytime beds has reached 9% of the total bed capacity of municipal hospitals in the Moscow region. In rural areas, it is organizational and economically feasible to use hospital-replacing technologies in large and medium-sized settlements. The main goal of the development of such forms of organization of medical care is to reduce the rates of hospitalization in round-the-clock hospitals and, accordingly, to reduce the costs of the health care system while maintaining the quality of medical care and its availability.
Considering the system of organization of inpatient care for the rural population, a number of problems can be identified, including such as the low rate of completeness of prehospital examination; delays in hospitalizations, especially in regional health care facilities; a tendency towards an increase in the number of independent appeals of rural residents to city and regional, including specialized, hospitals; high and growing rate of emergency hospitalizations; a significant proportion of unjustified hospitalizations. The actual state of rural hospitals of I and II levels (district and central regional hospitals) does not meet the requirements for either capacity, or material and technical equipment, or the composition and qualifications of personnel and specialization of the bed fund. In the district hospitals, a minimum amount of medical and diagnostic assistance is provided, patients who need not so much intensive therapy as medical and social assistance are hospitalized in them. Specialized inpatient care is increasingly shifting to regional and republican institutions. The problem of restructuring is being solved by transferring district hospitals to nursing homes, to the departments of rehabilitation treatment, rehabilitation and medical and social assistance, to medical outpatient clinics.
As part of the structural reorganization of inpatient medical care for the rural population, it is necessary to limit specialized care in the Central District Hospital (CRH), except for inter-district centers; close low-capacity (up to 25 beds) district hospitals or transfer them to the balance of social protection institutions; give priority to specialized inpatient care to regional hospitals and interdistrict centers. In the CRH, the emphasis should be placed on general inpatient care (therapeutic, surgical, pediatric, obstetric and gynecological) with planned operations that do not require high-tech medical equipment.
The reduction of the bed capacity and the number of hospitalizations, meanwhile, is not an end in itself, it is a tool to optimize costs in the health care system. So, in order to reduce the number of unjustified hospitalizations in a number of rural hospitals in the Samara region, diagnostic beds have been organized as part of the admission department for dynamic monitoring of patients who have no absolute indications for hospitalization. After carrying out medical and diagnostic procedures, only 33% of those admitted to the emergency department were hospitalized, which caused an economic effect. According to the standards, the financing schemes for outpatient and polyclinic institutions to pay for visits, and hospitals on a completed case, do not stimulate the chief doctors of hospitals to restructure the bed fund and expand the volume of out-of-hospital care. A hospitalization management system is proposed that allows to combine the prehospital and hospital stages into a single organizational and technical cycle, based on which the doctors of the district service strictly follow the algorithm for preparing patients for hospitalization. This is followed by an examination by the hospital by a specialist-manager for planned hospitalization, responsible for the level of prehospital examination, the validity of hospitalization, and an even distribution of the flow of patients to the hospital by days of the week and time of day.
Considering the modest medical and diagnostic capabilities, the lack of qualified medical personnel, the weak material and technical base and the lack of financial resources of rural medical and preventive institutions, a special role is currently assigned to the development of specialized consultative medical care, in particular the development of mobile forms of medical and diagnostic assistance, and especially creation of interdistrict consultative and diagnostic centers. To increase the real role of interdistrict centers, it is necessary to determine the correct forms of interaction and responsibility of the administrative bodies of municipalities included in the medical-sanitary zone; create an adequate financing system and an appropriate material and technical base; to ensure effective planning and control of the activities of inter-district centers as one of the levels of the system of providing specialized advice to the villagers. It is necessary to clearly define the areas served, taking into account the territorial location and transport accessibility, the number of the served population, the optimal distribution of types and volumes of care in the CRH system - the interdistrict center - the regional hospital, the organization and control of patient flows in the territorial medical-sanitary zone.
In rural areas, the problem of rational interaction between the social assistance system and health care is especially acute, given the greater proportion of elderly people living in rural areas. The literature data allow us to distinguish two main forms of medical and social services in rural areas: inpatient and out-of-hospital. The main types of inpatient institutions include medical and social departments based on rural hospitals, hospitals (departments, houses) of nursing care, hospices, as well as stationary institutions of social protection bodies (boarding houses, departments and houses of mercy, etc.). Outpatient forms of medical and social assistance to elderly rural residents include departments of outpatient medical and social assistance, outpatient services of social welfare agencies, and public organizations.
If in our country the medical and social direction in providing assistance to the elderly rural population began to actively develop from the early 1990s, then various forms of medical and social assistance began to appear abroad in the 1960s. Currently, medical and social assistance to elderly citizens in rural areas of developed foreign countries can be attributed to one of the main areas of medical care for the population, along with AFP. In European countries, out-of-hospital care for rural elderly people is mainly focused on home care with the wide involvement of social workers. According to researchers from Canada, in rural areas it is not worth organizing low-capacity day geriatric hospitals; it is advisable to have large inter-district centers where all the necessary specialists are concentrated. Despite the great variety of inpatient institutions of medical and social services noted abroad, the prevailing position in rural areas is occupied by nursing homes (departments), and to a lesser extent - by hospices. According to many authors, volunteers provide great assistance in the activities of these organizations.
Thus, according to the literature, there are a number of problems and directions in the optimization of medical care for the rural population. We must agree with the point of view that the reorganization of the structure of rural health care facilities, their resource provision allows for various forms of organization and the pace of transformations, but with the preservation common approaches... We are talking here about the introduction of a general practitioner (paramedic); the deployment of specialized services based on the CRH; organization of interdistrict centers in large CRHs; bringing the bed capacity to the real needs of the population; organization of catering services for rural residents in various forms.
The mechanism for organizing medical care involves an analysis of the state of health of the population; assessment of the organization of medical services; analysis of health care management and financing systems of the constituent entities of the Federation and municipalities; setting strategic goals, objectives and priorities in the development of health care and the activities of health care facilities; determination of the real need for medical services based on expert assessments; optimization of the network and structure of institutions in the context of the implementation of the municipal order.
At present, the concept of integrating health care services at the district level is being developed abroad, and efforts are united in the process of information exchange, planning, improving infrastructure, developing human resources, and not only in relation to health authorities. Steps are being taken to develop and integrate health care, education, transport, communications, housing, water supply, small business, agriculture under the control of municipalities. Community participation in integrated services increases overall satisfaction with their work. Integration tends to smooth out differences between geographic areas and socioeconomic groups in terms of service availability and usage. A key factor in the process of integrating district health services is PHC, which should be comprehensive (include health promotion, prevention, control and rehabilitation), holistic (to deal with the person as a whole in the context of the family and community), continuous (use a strategy of registering and registering regular follow-up of patients and monitoring of care).
In the current legislation on medical practice, there are not only significant shortcomings, but also gaps. Thus, the Constitution of the Russian Federation, designating health care systems, does not directly indicate the existence of a unified health care system in the Russian Federation, the constituent parts of which should be state, municipal and private health care systems. Failure to recognize the constitutionality of the existence of a unified health care system means that in the absence of appropriate legal regulation, federal bodies, state authorities of the constituent entities of the Russian Federation, local self-government bodies do not have a direct constitutional obligation to preserve and develop the corresponding health care system on their territories as a whole.
At the same time, despite the absence of direct indications of this in the Constitution of the Russian Federation, the analysis of the relevant articles provides indirect grounds for considering the health care system in the Russian Federation as a constitutional institution, since the social character of the state is attributed by the Constitution to the foundations of the constitutional order. The content of constitutional norms establishes the need for a unified health care system that unites various forms of state, municipal and private health care subsystems in a specific territory. The need for a unified health care system in the Russian Federation is also indicated by the Concept for the Development of Health Care and Medical Science in the Russian Federation.
The obligation of the state to ensure social equality in the realization of the right to health protection for all citizens of the Russian Federation presupposes the presence of organizational unity and consistency in the prevention of diseases and their treatment. This goal can only be effective when creating legislative framework, aimed at the formation of a health care system in the Russian Federation, which has unity and consists of three ordered levels (subsystems):
· Subsystems of the federal level;
· Subsystems of the level of a constituent entity of the Russian Federation;
Subsystems of the level of the municipality
At the same time, at each level, the corresponding components of health care systems - state, municipal and private - should be legislatively consolidated and coordinated. To effectively solve such a problem, it is necessary in the NLA to concretize the ways to achieve the goals specified in the Constitution, establishing in particular: a) the organizational structure and competence of the managerial component for the health care system at each level, not excluding the possibility of participation of representatives of the state, municipal and private health systems; b) the obligatory adoption of normative legal and individual acts of the control subsystem of a higher level for its level and subsystems more low level should be ensured by the existence of specific measures of responsibility for failure to comply with these acts.
First of all, this should refer to federal legislation, which should be reflected and concretized in the legislation of the constituent entities of the Russian Federation and legal acts of local governments.
Along with this, it is necessary to abandon the accepted definition of health care as a system of public health management bodies and institutions subordinate to them, and to consolidate in Federal law a fundamentally new content of this concept as a system of relations aimed at protecting human health.
In many countries of the world, one of the main trends is the strengthening of the role of the state in the field of public health protection. The experience of delineation of powers (decentralization) in the healthcare sector of foreign countries shows that, firstly, certain social and cultural conditions for decentralization are necessary, which are gradually developing; secondly, decentralization is accompanied by both positive and Negative consequences; thirdly, in any case, some strategic areas remain outside the boundaries of decentralization, incl. principles of state policy in the sphere of salary, fourthly, there is no single optimal model that can be used without any special changes in the basis for the construction of federal relations in the sphere of salary.
The main problem at present is that the legislation regulating the health sector does not form the organizational unity of all parts of the system. As a result, the ongoing reforms, affecting the development of certain areas, do not ensure the consistency, dynamism and integrity of the reform process.
The success of reforms in health care is determined by a single scientifically grounded strategy containing ways to overcome the crisis in the entire social sphere. It is obvious that the modern social policy in health care, built on an objective knowledge of the factors forming a healthy population and the state of the country's economy, requires a detailed study of legal regulation in the industry.
For this, first of all, it is necessary to improve the legislation regulating legal relations in health care and ensuring the organizational unity of the system as a whole, as well as establishing the responsibility of the constituent entities of the Russian Federation at all levels for the state of health of the population. For the functioning of the unified health care system of the Russian Federation, it is necessary to develop a Federal Law on the coordination of health care issues with the establishment of specific measures for its implementation, including administrative and criminal sanctions. The norms of this law should be concretized in the laws of the constituent entities of the Federation; in addition, both in the federal law and in the normative acts of the constituent entities of the Russian Federation, a boundary should be established for the exercise by municipalities of their powers.
Another important measure to ensure the organizational unity of health care, in accordance with paragraph "p" of Art. 71 of the Constitution, the federal authorities should establish minimum sufficient social standards of medical care, provided with an adequate amount of funding. The need to establish minimum social standards is also provided for by the norm of paragraph 6 of Art. 4 of the Law "On General Principles of Organization of Local Self-Government in the Russian Federation" dated 28.8.1995, No. 154-FZ. In turn, the health care subsystems of the constituent entities of the Russian Federation must exercise regulatory impact on the municipal health care systems. A real way to establish the unity of the state health care system should be such a coordination of actions, which is based on the organizing influence of the federal system on the territorial and municipal systems.
The presence of legislative registration of the vertical of the healthcare management system, as well as meaningful interrelationships of healthcare management bodies of the constituent entities of the Russian Federation, is the most important principle of healthcare management and gives the state healthcare system a complete pyramidal appearance with a developed lower level. For the state health care system, in our opinion, for any economic situation, administrative methods of management should be inherent, since these methods are quite consistent with the tasks that health authorities are called upon to solve: to ensure the implementation of a unified policy in the field of health care, coordinate the work of various services, control the quality of medical care, introduce standardization issues in medical activities, etc. etc. Currently, it is advisable to reduce the independence of medical organizations in economic sphere because they have a freedom inadequate to their economic responsibility. One of the ways to legally restore the power influence of the federal health care system in the territory when creating an administrative vertical is, in our opinion, changing the relationship between the competence of state and municipal formations. It is important to establish in the Federal Law the grounds on which state and municipal health care institutions can either be allowed or denied the right to provide paid medical services. The problem here is the need to combine interests, both public and private; their balance, reflected in the law, must not only be measured economically, but also give this regulation. In our opinion, the commercial activity of state and municipal healthcare organizations is an undesirable phenomenon for two reasons. First, the power represented by the committees will suppress the market for medical services in every possible way. Secondly, the government will be corrupted. This means that it is necessary to introduce this power into a framework: on the one hand, to give it the opportunity to protect the public interest, on the other, not to give the opportunity to infringe on the private health care system. The owner of the municipal health care organizations is the population of the territories, and only it is necessary to be guided by it when solving all issues. The health care system, as well as other sectors of the social sphere, is faced with the problem of privatization associated with the optimal construction of the system of organization and management. And here, it seems to me, we must take into account one incongruity that has arisen in our law. We have essentially abandoned the variety of forms of ownership. We know only state, municipal and private, it is not clear why we have discarded collective property, but you cannot transfer most of the medical complexes into private hands. Even if there is such a structure that will swallow all this, such an option is undesirable from the point of view of the interests of the population. Therefore, it is advisable to revive collective property. And yet, according to the current legislation, it is possible to approach the privatization of one or another healthcare organization as an object without taking into account the processes in which this object is involved. We propose that during privatization we consider not objects, but completely different entities, consisting of peculiar processes. When preparing a healthcare organization for privatization, it is necessary to consider its activities as a whole and determine in two aspects:
1. Subject of privatization - all infrastructural processes remain in state (municipal) ownership;
2. All fast processes are moving into the private health care system.
Conclusion
It is necessary to take for granted the fact that in the transitional period one cannot do without a rigid regulatory function of the state and law in building a new health care system. Throwing into the market (creating a multi-structure) without a legal basis means reproducing the conditions of the period of initial capital accumulation with all the ensuing socio-political consequences that our country went through in 1992-1995. Law not only reflects the existing social system, but also acts as a regulator of social relations, bringing the behavior of people and organizations in line with the interests of society. The law plays a leading role in defining the principles of the activities of organizations and the activities of state health authorities, their competence, the form and procedure for solving new problems.
Having analyzed the situation in healthcare, we propose the following set of measures to improve the availability and quality of medical care.
1) Having decided to support primary health care at the federal level, the regions should be much more active in supporting primary health care. There is understanding and striving for this in the regions. But we need a mechanism that will allow directing regional budget funds directly to municipal medical institutions, bypassing municipalities, for example, through regional health authorities. Otherwise, the municipality will be tempted to spend money on other, equally important and urgent needs.
2) To increase the availability of high-tech medical care, it is advisable to combine the centers of high medical technologies into a single all-Russian specialized medical services with branches in the regions. This will ensure the development of unified standards for diagnostics, treatment, medical rehabilitation, a unified methodology for training highly qualified medical personnel. It will increase the coordinating role of the Ministry of Health and Social Development of Russia, which is especially important in these conditions of the redistribution of powers and the transfer to regional and municipal levels of a significant part of the obligations to provide medical care to the population.
3) Prevention should take a special place. At all levels, target programs for the prevention of diseases should be developed already this year, including programs for general medical examination, vaccination of the population, especially, of course, children.
Along with this, it is extremely necessary to establish a widespread healthy lifestyle, the formation of a kind of cult of health, the development of physical culture and sports. This also requires special programs at all levels.
4) With regard to the material and technical base, the most urgent, namely, the equipment of the primary care has already been provided. But the decline in the domestic production of medical equipment, modern complex medical equipment and medicines is obvious.
Therefore, it is necessary to develop and implement federal targeted programs for the development of the medical and pharmaceutical industry in Russia.
5) The key link in the system of measures to improve the availability and quality of medical care should be strengthening the human resources of health care and a radical improvement in the social well-being of medical workers. Make the amount of remuneration in health care dependent on the quality of medical services, and introduce a number of organizational measures to increase responsibility for the improper provision of medical services.
In addition, along with the support of the primary care staff, we are obliged to provide measures for the retention of specialists of the highest category.
6) No systemic changes in health care will take place without improving its legislative base. The basic, system-forming law on healthcare in the Russian Federation has not yet been adopted.
The main directions in improving the organization of medical care are the development of primary health care based on municipal health care, the redistribution of part of the volume of care from the inpatient sector to the outpatient one.
Primary health care is the main link in the provision of medical care to the population.
A special role is assigned to the development of the institution of general (family) practice physician. Consultative and diagnostic services should be developed in polyclinics. On their basis, departments of medical and social rehabilitation and therapy, nursing services, day hospitals, centers for outpatient surgery and medical and social assistance, etc. can be deployed.
Measures to introduce modern technologies in intensive care units, cardiology and cardiac surgery, oncology, diagnostics and treatment of socially significant diseases require state support.
It is necessary to strengthen the ambulance service, make it more mobile and equipped with modern facilities for the provision of emergency medical care and emergency hospitalization of patients.
It is required to increase the role of scientific centers and research institutes in the development and implementation of effective medical technologies, the use of unique methods of diagnosis and treatment.
It is necessary to take measures of state support to improve rehabilitation assistance, the development of sanatorium-resort organizations of the health care system, health institutions and organizations.
To improve the quality and accessibility of medical care to the rural population, it is necessary to form treatment and diagnostic complexes on the basis of central regional hospitals, including municipal rural medical institutions, to develop mobile forms of medical diagnostic and advisory assistance, to create inter-district clinical diagnostic centers.
It is necessary to integrate departmental medical institutions into the general health care system on a unified regulatory framework, taking into account their industry characteristics and location.
The emerging private sector will play an important role while maintaining the dominant role of public and municipal health care.
The creation of conditions for its development is an essential element of structural transformations in health care.
It is necessary to ensure that medical organizations, individuals engaged in private medical activities, state and municipal organizations have equal rights to work in the compulsory health insurance system and to participate in the implementation of state and municipal targeted programs. The participation of medical organizations of various forms of ownership in the implementation of state health programs, municipal orders should be carried out on a competitive basis.
State and municipal medical and preventive institutions performing functions that are not bound by the framework of a unified technology for the provision of medical care should have broad powers in matters of property use and staff remuneration.
Bibliography
1. The Constitution of the Russian Federation: Adopted by popular vote on December 12, 1993 (as amended on July 25, 2003) // SZ RF.-2003.
2. Decree of the Government of the Russian Federation of November 5, 1997 No. 1387 "On measures to stabilize and develop health care and medical science in the Russian Federation."
3. The concept of development of health care and medical science in the Russian Federation. M., 2005.
4. Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens of 03/07/2005.
5. Belova N.V., Suslonova N.V. Preservation of health care // Problems of health care management. 2004. No. 1 (14). S. 7-8.
6. Galkin R.A. Sandreeva S.Kh., Fedoseeva L.S. Healthcare // Problems of healthcare management. 2001. No. 2. S. 38-40.
7. Galkin R.A., Gekht I.A. Suslin S.A. Organization of medical and social assistance to the elderly in rural areas. Samara, 2001 .-- 512 p.
8. Kalininskaya A.A. Gudanova E.N., Matveev E.N. Health economics // Problems of social hygiene, health care and history of medicine. 2002. No. 1. S. 43-46.
9. Kirillov A.V. Health problems // Russian family doctor. 2001. No. 1. S. 43.
10. Kozhevnikov V.V. Problems of Territorial Health Care: Collection of Scientific Papers. M., 2003. Issue. 5. - 112 p.
11. Lakunin K.Yu. Provision of medical care for the population of rural municipalities and approaches to planning it in the new socio-economic conditions: Abstract dis. ... Dr. med. Science. M., 2001.
12. Ludyapova E.Yu. Organizational and economic substantiation of the use of hospital-replacing technologies in rural areas: Abstract dis. ... Cand. Honey. Science. SPb, 2002.S. 40.
13. Mikhailova Yu.V., Magnitsky V.A. Healthcare // Chief physician. 2004. No. 9.P. 30.
14. Mikhailova Yu.V., Magnitsky V.A. Health care management // Chief physician. 2002. No. 6. P. 4.
15. Public health and health care. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006 .-- 668 p.
16. Pascal A.V. Scientific substantiation of organizational forms and ways to improve the efficiency and quality of out-of-hospital care for the rural population of the region (for example Saratov region): Abstract dis. ... Cand. Honey. Science. SPb, 2002.S. 44.
17. Petrov P.P., Kalzhekov T.K. Problems of organizing medical care for the rural population. Alma-Ata, 1990 .-- 328 p.
18. Semenov V.Yu., Tamazyan G.V., Mikhnevich N.N. and other Management in the field of health // Health. 2004. No. 5.P. 32.
19. Stepanov V.V., Finchenko E.A. The main directions of rural health care. Novosibirsk, 2003 .-- 228 p.
20. Tatarnikov M.A. Health care reform in the Russian Federation: problems and prospects for their solution. M .: UNITI-DANA, 2003 .-- 336 p.
21. Finchenko E.A., Stepanov V.V. Healthcare // Problems of healthcare management. 2003. No. 5 (12). S. 5-13.
22. Shchipin V.O. Structural transformation in health care. M .: Unity, 1997 .-- 448 p.
Mikhailova Yu.V., Magnitsky V.A. Health care management // Chief physician. 2002. No. 6. P. 4.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 81.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 90-91.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 99.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 103.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 105.
Lakunin K.Yu. Provision of medical care for the population of rural municipalities and approaches to planning it in the new socio-economic conditions: Abstract dis. ... Dr. med. Science. M., 2001.
Kalininskaya A.A. Gudanova E.N., Matveev E.N. Health economics // Problems of social hygiene, health care and history of medicine. 2002. No. 1. S. 43-46.
Shchipin V.O. Structural transformation in health care. M .: Unity, 1997.S. 113.
Stepanov V.V., Finchenko E.A. The main directions of rural health care. Novosibirsk, 2003.S. 106.
Petrov P.P., Kalzhekov T.K. Problems of organizing medical care for the rural population. Alma-Ata, 1990.S. 200.
Pascal A.V. Scientific substantiation of organizational forms and ways to improve the efficiency and quality of out-of-hospital care for the rural population of the region (on the example of the Saratov region): Abstract dis. ... Cand. Honey. Science. SPb, 2002.S. 44.
Ludyapova E.Yu. Organizational and economic substantiation of the use of hospital-replacing technologies in rural areas: Abstract dis. ... Cand. Honey. Science. SPb, 2002.S. 40.
V.V. Kozhevnikov Problems of Territorial Health Care: Collection of Scientific Papers. M., 2003. Issue. 5.S. 66-70.
Galkin R.A., Gekht I.A. Suslin S.A. Organization of medical and social assistance to the elderly in rural areas. Samara, 2001.S. 30.
See: Yu.V. Mikhailova, V.A. Magnitsky. Healthcare // Chief physician. 2004. No. 9.P. 30.
Public health and healthcare. Textbook Public health and health care. Textbook for universities / Ed. Yu. P. Lisitsyna. M .: UNITI-DANA, 2006.S. 107.