Healthcare Problems and Ways to Solve Them S. I. Kolesnikov Deputy Chairman of the Committee on Health Protection Member of the Presidium of the RAMS ACADEMIC OF RAMS Foundation ISP and R (Fedorova) Moscow,
CONDITIONS OF PROGRESS IN RUSSIA 1. Political will of state leaders and consent of bureaucrats 1. Political will of state leaders and consent of bureaucrats 2. Stable financing and predictable tax policy 2. Stable financing and predictable tax policy 3. Consent in society 3. Consent in society 4. Management and training 4. Management and training 5. Interaction with leading partners and exchange of experience 5. Interaction with advanced partners and exchange of experience 6. Public-private partnership 6. Public-private partnership
Efficiency of the health care system in Russia Per capita budget expenditures on health care place in the world. Per capita health care budgets ranked in the world. By the efficiency of the health care system - 130th place (WHO) By the efficiency of the health care system - 130th place (WHO) Dissatisfaction of the population and doctors with health care - more than 60%. Dissatisfaction of the population and doctors with health care - more than 60%.
Reforming health care is an urgent need: improving the health of the nation; improving the health of the nation; maintaining social stability in society; maintaining social stability in society; improving the quality of medical care to the level of developed countries; improving the quality of medical care to the level of developed countries; optimizing government spending while increasing the efficiency of investments; optimizing government spending, while increasing the efficiency of investments reducing structural imbalances (restructuring) reducing structural imbalances (restructuring)
1. There is no unified health protection system - 3 autonomous systems and different types of institutions (being addressed without sufficient funding). 1. There is no single health care system - 3 autonomous systems and different types of institutions (solved without sufficient funding). 2. State guarantees and financial resources for the provision of free medical care are not balanced, inpatient care is mainly financed, the volume of paid services is growing (it is not being resolved and the prospects are unclear). 2. State guarantees and financial resources for the provision of free medical care are not balanced, inpatient care is mainly financed, the volume of paid services is growing (it is not being resolved and the prospects are unclear). 3. There is no stimulation of investments and payments in health care for individuals and legal entities, which does not allow legalizing payments (not being solved). 3. There is no stimulation of investments and payments in health care for individuals and legal entities, which does not allow legalizing payments (not being resolved). Health problems:
4. Low motivation of managers and employees to improve the quality of work, and insurers - to ensure the interests of citizens (mechanisms have not yet been created). 4. Low motivation of managers and employees to improve the quality of work, and insurers - to ensure the interests of citizens (mechanisms have not yet been created). 5. Sharp differences in the availability and quality of medical care between the constituent entities of the Russian Federation, municipalities, in the city and in the countryside, the poor and the rich (partially solved). 5. Sharp differences in the availability and quality of medical care between the constituent entities of the Russian Federation, municipalities, in the city and in the countryside, the poor and the rich (partially solved). 6. There is no single information space (register of insured, patients, capacities, drugs, telemedicine, etc.) - being resolved 6. There is no single information space (register of insured, patients, capacities, medicines, telemedicine, etc.)
7. Lack of elements of professional self-regulation (not being resolved) 7. Lack of elements of professional self-regulation (not being resolved) 8. Underdeveloped public-private partnership (not being resolved). 8. Underdeveloped public-private partnership (not being resolved). 9. Underdevelopment of public institutions for monitoring the health care system (solved slowly and ineffectively). 9. Underdevelopment of public institutions for monitoring the health care system (solved slowly and ineffectively). 10. Minimum participation of citizens in maintaining their health. There is no effective system of education, promotion and stimulation of a healthy lifestyle (it is poorly solved). 10. Minimum participation of citizens in maintaining their health. There is no effective system of education, promotion and stimulation of a healthy lifestyle (it is poorly solved). 11. Lack of real responsibility of the authorities for the state of health of the population. 11. Lack of real responsibility of the authorities for the state of health of the population.
Resource provision The outdated system of personnel training, both doctors and, in particular, managers (managers) working in the social sphere (who do not have medical education) is not being solved. The outdated system of personnel training, both doctors and, in particular, managers (managers) working in the social sphere (without medical education) is not being solved. There is no developed modern domestic pharmaceutical and medical industry (partly being solved) No developed modern domestic pharmaceutical and medical industry (partly being solved)
Solutions to overcome the crisis in healthcare () 1. DLO 2. Monetization of benefits 3. National priority project "Health" 4. Reform of legislation and regulatory framework... 5. Raising premiums and modernizing healthcare
RESULTS OF PNP “ZDOROVIE” An additional 825 thousand lives of citizens of the Russian Federation were saved (0.6% of the population of the Russian Federation). But in years. the dynamics in improving the health status of the population of the Russian Federation has slowed down
The reasons for the slowdown in the improvement of the health status of the population of the Russian Federation Decrease in the growth of health care costs in constant prices Unsatisfactory response of the health care system to abnormal weather and environmental conditions in the summer of 2010 Unresolved key health problems
Problems to be solved (before the appearance of social protests) To oblige all levels of government to put things in order (queues, paid services, rudeness, etc.) in medical organizations, up to the removal of municipal and regional managers, leaders, doctors from their posts. To oblige all levels of government to put things in order (queues, paid services, rudeness, etc.) in medical organizations, up to the removal of municipal and regional managers, managers, doctors from their posts. Urgently organize, instead of FAPs, equipped offices of family doctors (paramedics) with the approach of assistance to the population, allowing the circulation of drugs in these points without obtaining a pharmaceutical license. Urgently organize, instead of FAPs, equipped offices of family doctors (paramedics) with the approach of assistance to the population, allowing the circulation of drugs in these points without obtaining a pharmaceutical license. Urgently increase funding for the system and transfer all organizations to sectoral (incentive) wage systems, using both modernization and a direct increase in the wage bill. Urgently increase funding for the system and transfer all organizations to sectoral (incentive) wage systems, using both modernization and a direct increase in the wage bill. Introduce social and other benefits for well-performing health workers (bonuses, utility bills, increased use of honorary titles and social incentives). Introduce social and other benefits for well-performing health workers (bonuses, utility bills, increased use of honorary titles and social incentives). Conduct clinical examination of the working population by the forces of city and regional medical organizations. Conduct clinical examination of the working population by the forces of city and regional medical organizations.
Key problems that need to be consistently resolved Increase in budgetary funding up to 1000 US $ per capita per year (WHO recommendation). Do not reduce the budgetary component (!!!). Growth of budgetary funding to 1000 US $ per capita per year (WHO recommendation). Do not reduce the budgetary component (!!!). Careful introduction of standards and rules (do not close regional medical organizations). Careful introduction of standards and rules (do not close regional medical organizations). A sharp increase in incentive mechanisms that depend on the quality of work. A sharp increase in incentive mechanisms that depend on the quality of work. To create a system of training and continuous education of acutely deficient personnel, including managers. To create a system of training and continuous education of acutely deficient personnel, including managers. Training of social managers for municipalities and subjects of the Federation, competent in the field of state policy and the consequences of making managerial decisions. Training of social managers for municipalities and subjects of the Federation, competent in the field of state policy and the consequences of making managerial decisions. Introduction of strict responsibility of regional authorities for the indicators of medical care of the population. Introduction of strict responsibility of regional authorities for the indicators of medical care of the population.
17 Billion RUB Billion rubles 2010 2011 2012 2013% to 2010% to 2011% to Education, 451,699.7 Health care, 343,389.9 Social policy, 9 Physical education and sports, 02967.82690.1
LAWS (AMENDMENTS) FZ 94 On procurement for state and municipal needs (auctions and quotes) FZ 217 On the creation of innovation firms in research institutes and universities for the commercialization of IP On concession agreements in Healthcare (Government Resolution) Transition to Insurance Payments in the MHIF, FSS and the Pension Fund On Self-Regulatory Organizations (SRO) (United Medical Community)
NEW LAWS, amendments () On insurance of liability of medical organizations On the protection of the Health of Citizens of the Russian Federation (municipal) institutions Law On CHI On the Circulation of Medicines and Amendments to a Number of Laws On Special Economics. zones
Interference of new laws () FZ 83 "On ... budgetary institutions" On the circulation of medicines On education Law "On CHI" (+ on drug insurance?)
The increase in the size of insurance premiums for compulsory medical insurance by 2% will be in 2011 and 2012. 230 billion rubles per year According to the RF Accounts Chamber, the deficit of financial support for territorial programs of state guarantees (current financing of free medical care for citizens) in 2009 alone amounted to about 385 billion rubles and according to preliminary estimates in 2010 the situation did not improve. RISK: possibly even more significant non-fulfillment of social obligations to implement the constitutional rights of citizens to free medical care
Prospects for financial changes Increase: Minimum insurance premiums for the non-working population (5 proposed, but 10 thousand rubles are needed) Minimum insurance premiums for the non-working population (5 are proposed, but 10 thousand rubles are needed) An increase in these payments annually since 2013 by 25% until 2015 An increase from 2013 annually in these payments by 25% until 2015. Decrease: clinics and the National Project "Health"
Article 15. Transfer of the exercise of the powers of the Russian Federation to the constituent entities of the Russian Federation 1. The Russian Federation transfers to the constituent entities: 1. The Russian Federation transfers to the constituent entities: 1) licensing of: a) medical organizations of municipal and private health care systems (with the exception of VMP); b) pharmaceutical activities (with the exception of the activities of wholesale trade organizations and pharmacies of federal organizations); 1) licensing: a) medical organizations of municipal and private health care systems (with the exception of VMP); b) pharmaceutical activities (with the exception of the activities of wholesale trade organizations and pharmacies of federal organizations); c) circulation of narcotic, psychotropic drugs and precursors; c) circulation of narcotic, psychotropic drugs and precursors; 2) organization of the provision of medicines for "seven nosologies". 2) the organization of the provision of medicines for "seven nosologies".
Article 15. Transfer of the exercise of the powers of the Russian Federation to the constituent entities of the Russian Federation 2. Funds for the exercise of powers transferred in accordance with Part 1 shall be provided in the form of subventions from the federal budget. 2. Funds for the exercise of powers transferred in accordance with Part 1 shall be provided in the form of subventions from the federal budget. 3. The total amount of funds is determined on the basis of methods approved by the Government of the Russian Federation. 3. The total amount of funds is determined on the basis of methods approved by the Government of the Russian Federation. 5. Funds are targeted and cannot be used for other purposes. 5. Funds are targeted and cannot be used for other purposes.
Article 15. Transfer of the exercise of powers of the Russian Federation to the constituent entities of the Russian Federation 8. The federal register of persons with hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher's disease, malignant neoplasms of lymphoid, hematopoietic and related tissues, multiple sclerosis, after organ and (or) tissue transplantation is maintained by the authorized federal body. 8. The federal register of persons with hemophilia, cystic fibrosis, pituitary dwarfism, Gaucher disease, malignant neoplasms of lymphoid, hematopoietic and related tissues, multiple sclerosis, after organ and (or) tissue transplantation, is maintained by the authorized federal body.
Article 15. Transfer of the exercise of the powers of the Russian Federation to the constituent entities of the Russian Federation 7. The federal authority: 7. The federal authority: 2) issues guidelines and instructions on the delegated powers binding on the authorities of the constituent entity of the Russian Federation; 2) issues guidelines and instructions on delegated powers that are binding on the authorities of the constituent entity of the Russian Federation; 3) coordinates the appointment (dismissal) of the heads of the executive authorities of the constituent entities of the Russian Federation exercising the delegated powers; 3) coordinates the appointment (dismissal) of the heads of the executive authorities of the constituent entities of the Russian Federation exercising the delegated powers;
Article 44. Medical assistance to those suffering from rare (orphan) diseases 1. Rare (orphan) diseases are diseases that have a prevalence of no more than 10 per population. 1. Rare (orphan) diseases are diseases that have a prevalence of no more than 10 per population. 2. The list of orphan diseases is formed by the authorized federal executive body on the basis of statistical data and is posted on the official website. 2. The list of orphan diseases is formed by the authorized federal executive body on the basis of statistical data and posted on the official website. 3. The list of orphan diseases is approved by the Government of the Russian Federation 3. The list of orphan diseases is approved by the Government of the Russian Federation
Article 83. Financial provision of medical care and sanatorium-resort assistance 9. Financial provision of citizens with medicines for the treatment of diseases included in the List of life-threatening acute and chronic progressive rare (orphan) diseases leading to a reduction in the life expectancy of a citizen or his disability (with the exception of diseases , specified in paragraph 2 of part 1 of article 15), is carried out at the expense of the budgets of the constituent entities of the Russian Federation. 9. Financial provision of citizens with medicines for the treatment of diseases included in the List of life-threatening acute and chronic progressive rare (orphan) diseases leading to a reduction in the life expectancy of a citizen or his disability (with the exception of the diseases specified in paragraph 2 of part 1 of Article 15) is carried out for funds account of the budgets of the constituent entities of the Russian Federation.
Article 74. Restrictions imposed on medical and pharmaceutical workers ("medreps") 1. Health workers and managers are not entitled to: 1. Health workers and managers are not entitled to: 1) accept from organizations involved in the development, production and (or) sale of drugs, medical products, or with the rights to the trade name of a drug, drug wholesalers, pharmacy organizations gifts, money (except for remuneration under contracts when conducting clinical studies or tests in connection with pedagogical and (or) scientific activities), incl. to pay for entertainment, recreation, travel to the place of rest, as well as take part in entertainment events, at the expense of companies (representatives); 1) accept gifts, money from organizations engaged in the development, production and (or) sale of drugs, medical devices, or with rights to the trade name of a drug, drug wholesalers, pharmacy organizations (except for remuneration under contracts when conducting clinical trials or tests, in connections with pedagogical and (or) scientific activities), incl. to pay for entertainment, recreation, travel to the place of rest, as well as take part in entertainment events, at the expense of companies (representatives);
Article 74. Restrictions imposed on medical and pharmaceutical workers ("medreps") 2) conclude agreements with the company on the prescription or recommendation to patients of drugs, medical devices (with the exception of clinical trials); 2) conclude agreements with the company on the prescription or recommendation of drugs, medical devices to patients (with the exception of clinical trials); 3) receive samples from the company for delivery to patients (except for clinical studies); 3) receive samples from the company for delivery to patients (except for clinical studies); 4) when prescribing a course of treatment, provide the patient with inaccurate, incomplete or distorted information about the medications, medical devices used, incl. hide information about the availability of similar drugs and medical devices in circulation; 4) when prescribing a course of treatment, provide the patient with inaccurate, incomplete or distorted information about the medications, medical devices used, incl. hide information about the availability of similar drugs and medical devices in circulation;
Article 74. Restrictions imposed on medical and pharmaceutical workers ("medreps") 5) not to receive company representatives, with the exception of clinical trials and tests, to participate in the manner prescribed by the organization's administration in meetings of medical workers and other events related to raising the professional level of medical workers or providing information on side effects; 5) not to receive company representatives, with the exception of clinical studies and trials, to participate in the manner prescribed by the organization's administration in meetings of health workers and other events related to raising the professional level of health workers or providing information on side effects; 6) prescribe medicines and medical devices on forms containing information of an advertising nature, as well as on forms on which the name of the medicine or medical device is pre-printed. 6) prescribe medicines and medical devices on forms containing information of an advertising nature, as well as on forms on which the name of the medicine or medical device is pre-printed.
Article 74. Restrictions imposed on medical and pharmaceutical workers ("medreps") 2. Pharmaceutical workers and heads of organizations: 2. Pharmaceutical workers and heads of organizations: 1) accept gifts, money, including payment for entertainment, recreation, and also accept participation in entertainment events at the expense of the company; 1) accept gifts, money, including payment for entertainment, recreation, as well as take part in entertainment activities at the expense of the company; 2) receive from the company samples of medicines, medical devices for delivery to the population; 2) receive from the company samples of medicines, medical devices for delivery to the population; 3) conclude agreements with the company on the offer to the population of certain medicines and media products; 3) conclude agreements with the company on the offer to the population of certain medicines and media products; 4) provide inaccurate, incomplete or distorted information about available medicines with the same INN, medical devices, including hiding information about the availability of medicines and medical devices with a lower price. 4) provide inaccurate, incomplete or distorted information about available medicines with the same INN, medical devices, including hiding information about the availability of medicines and medical devices with a lower price.
Article 75. Settlement of a conflict of interest in the implementation of medical and pharmaceutical activities - 1. Conflict of interest is a situation in which a medical or pharmaceutical worker, while carrying out professional activity there is a personal interest in obtaining, personally or through a representative of the company, material benefits or other advantages, which affects or may affect the proper performance of his professional duties due to a contradiction between the personal interest of a medical or pharmaceutical worker and the interests of the patient. 1. Conflict of interest - a situation in which a medical or pharmaceutical worker, in the course of his professional activities, has a personal interest in obtaining, personally or through a company representative, material benefit or other advantage, which affects or may affect the proper performance of his professional duties due to a contradiction between personal the interest of the medical or pharmaceutical worker and the interests of the patient. 2. In the event of a conflict of interest, the employee is obliged to inform the head of the organization in writing, and individual entrepreneurs to the authorized federal executive body. 2. In the event of a conflict of interest, the employee is obliged to inform the head of the organization in writing, and individual entrepreneurs to the authorized federal executive body.
Article 75. Settlement of conflicts of interest in the implementation of medical and pharmaceutical activities 3. The head of a medical or pharmaceutical organization within seven days is obliged to notify the authorized federal executive body of this in writing. 3. The head of a medical or pharmacy organization shall, within seven days, notify the authorized federal executive body of this in writing. 4. For the settlement of conflicts of interest, the authorized federal body shall form a commission for the settlement of conflicts of interests and approve the regulations on it. 4. For the settlement of conflicts of interest, the authorized federal body shall form a commission for the settlement of conflicts of interests and approve the regulations on it. 5. The composition of the commission must exclude the possibility of a conflict of interest that could affect the decisions taken by the commission. 5. The composition of the commission must exclude the possibility of a conflict of interest that could affect the decisions taken by the commission.
PAGE_BREAK - 1. The concept and history of the formation of health care in Russian Federation 1.1 Concept of health care
The concept of "health care" means activities to preserve, improve, ensure and enhance the health of various groups of the population. The main legislative acts enshrine the human right to health protection and promotion. Optimization of the health care system is the most important part of the socio-economic policy of the state. Health care is viewed as a state system with the unity of goals, interaction and continuity of services (therapeutic and prophylactic), universal availability of qualified medical care, and a real humanistic orientation.
The priority structural element of the health care system is the preventive activity of medical workers, the development of medical and social activity and attitudes towards a healthy lifestyle among various groups of the population.
The main direction in the development and improvement of health care at the present stage- protection of mothers and children, the creation of optimal socio-economic, legal and medico-social conditions for strengthening the health of women and children, family planning, solving medico-demographic problems.
The state nature of health care provides funding, training and improvement of personnel. The activities of bodies and institutions are carried out on the basis of state legislation and regulatory documents. The principle of the unity of medical science and practice is implemented in the form of joint activities and implementation scientific developments in health care institutions.
Among the most important theoretical problems health care include: social conditioning of public health, disease as a biosocial phenomenon, the main categories of health care (public health, material and economic base, personnel, etc.), forms and ways of developing health care under various socio-economic conditions, etc.
The World Health Organization has identified 4 categories of generalized indicators that characterize the state of health in the country: 1) indicators related to health policy; 2) social and economic indicators; 3) indicators of the provision of medical and social assistance; 4) indicators of health status.
1.2 History of the formation of healthcare in Russia
Late 17th - early 18th century became a significant time in the history of Russia. Reforms of the outstanding statesman and the commander, talented and energetic Peter I, allowed to overcome the cultural self-isolation of Russia (which, however, was never absolute), to open a “window to Europe”, to establish contacts and mutual exchange, to join the common European culture and civilization. Peter's reforms, the tension 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 educated person, highly appreciated 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 the professor of anatomy Ruysch, was present during operations, and when he saw in his anatomical office a perfectly dissected corpse of a child who smiled as if alive, he 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 hands with Levenguk and expressed his special gratitude 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 Boerhava, a medical luminary of that time, saw how the professor "separated" the corpse and "told" its parts to the students, 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. Usually, 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) he 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 used to be that close people who suffered from any ailment that required surgical assistance were horrified at the thought that the tsar might find out about their illness and, having appeared with tools (Peter I had his own surgical instruments, which included a pair of lancets, a knife, pliers for pulling out teeth, scissors, a probe for wounds, etc.), will offer his services as a surgeon: of course, it was impossible to refuse the king, but also to trust him as an operator, as a doctor, as a doctor, it was also impossible. After all, as they say, after him there was a whole bag with his teeth pulled out - a monument to his dental practice.
During the reign of Peter I, which opened, in fact, the history of Russia in the 18th century, distinctive feature the organization of medical affairs in the country continued to be of a state character. 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 pledged to build "zemstvo dependent state hospitals for the charity of the orphan, the sick and the disabled and for the elderly people of both sexes": as a result, 10 hospitals and over 500 infirmaries were created in the country during his lifetime. 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 has lacked until now; God only grant that many never need to be brought here! "
It should be emphasized that it was Peter I who provided state support to 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 in 1714 Metropolitan Job 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 important state affairs... Moreover, in a decree of January 16, 1712, Peter I directly prescribed: "In all the provinces, 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 arch-father."
In another tsarist decree it was emphasized: “Just as about the same deeds, 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 ... such babies were 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 followed that any Russian or foreigner who wishes to open a free pharmacy with the permission of the government will receive a place without money 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 for the service in the newly created Russian fleet were hired along with captains, gunners, navigators and other specialists and 52 doctors: 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 at the beginning of the 18th century. a school of mathematical and navigational sciences (1701), artillery schools (1701), an engineering school (1713), Marine Academy(1713), mining and industrial craft schools (1719) and a number of others: the St. Petersburg Academy of Sciences (1725), and then Moscow University (1755) were created. 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 healers to great art; for the sake of this intention, although at the beginning, physicians and healers should be provided. "
The hospital schools created in Russia were fundamentally different from those that existed in Western Europe medical schools - medical faculties of universities. As you know, their graduates - doctors of a therapeutic profile - received mainly theoretical education. In contrast, surgeons who did not have a 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 in 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, 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 royal 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 the beginning was made, and for the first time several sick people were brought into that house ”.
At the same time, the first in the country 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 that replaced it) spent part of the funds received by the clergy from the monastic estates, from fees from the "crown memorials" (they were paid at 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 looked at learning as labor and for the most part did it with great willingness.
However, not all of those who entered the Moscow hospital school passed full course learning. So, in 1712, Dr. Bidloo wrote to Peter I: “I took in different years and numbers 50 people before surgical science, of whom 33 remained, 6 died, 8 fled (from schools then, as V.O. Klyuchevsky wrote, 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 on full boarding with the state, lived at the hospital in separate rooms, had a common table, received uniforms and a salary. The salary was 1 ruble per 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 they called him 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 - a 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 to Russia. In addition, Bidloo carried out numerous assignments for 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" placed a message that "an anatomical theater has been built in Moscow, which is entrusted to the supervision of Dr. Bidloo, a Dutchman and a tsarist 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. "To surgery," taught future doctors Dr. Bidloo, "are related so that the surgeon knows: 1. Anatomy, which is the knowledge of the whole human body from the outside and from the inside." 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 pattern 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 for treatment such exotic, but used medicines as dog and fox fat, wolf teeth, antler, hare ankles, etc.
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 even 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 is to Peter I that Russian medicine owes much 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. At the same time, a distinctive feature of Russian medicine continued to be its state character.
The training of medical personnel was carried out in hospital schools (since 1707), medical-surgical schools (since 1786), and since 1798 - in 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 MV 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 concrete measures to improve its organization.
In the first half of the 19th 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).
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--PAGE_BREAK - 2. Analysis of the national project to improve governance in health care 2.1 New in Russian legislation in the field of health care
From 01.01.05 the Federal Law “On Amendments to the Legislative Acts of the Russian Federation and the Recognition of Invalidation of Certain 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 the executive bodies of state power of the constituent entities of the Russian Federation "and" On the general principles of organizing local self-government in the Russian Federation "dated 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, order of organization and activities of federal government bodies of the state health care system were declared invalid. Also from the Fundamentals, 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 are excluded. 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. The 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 government bodies to determine the nomenclature of specialties in health care have been supplemented by the powers to determine the nomenclature of organizations in health care. This is due to possible changes in the legislation on the organizational and legal forms of organizations, including healthcare organizations, in the near future.
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 with 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 government bodies, as well as the principles of the rule of law with a socially oriented market economy ”(preamble of 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, today 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 is consistent with 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 a new edition, which led to a change in the content of powers. The powers of the bodies of state power 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 the 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 of 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 measures of social support (in the old terminology - benefits) provided to certain groups of the population in the provision of medical and social assistance and drug provision under the current legislation is now 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, diagnostics 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.
In accordance with the amendments made, the jurisdiction of local self-government bodies (Article 8) includes control over the observance of 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 medicines 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 medical care standards, providing citizens with medicines and medical products in the jurisdictional territory; security environment and ensuring environmental safety.
It should be noted that the organization and financing of specialized medical care in municipal health care organizations did not fall within the powers of the state authorities of the constituent entities of the Russian Federation, or the powers 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 health care system (Article 12) includes federal executive bodies in the field of health care, executive bodies of the constituent entities of the Russian Federation in the field of health care, the Russian Academy of Medical Sciences, which, within their competence, plan and implement measures to protect health. citizens.
The state health care system also includes state-owned and subordinate to the management bodies of the state health care system, treatment-and-prophylactic and research institutions, educational institutions, pharmaceutical enterprises and organizations, pharmacies, sanitary and prophylactic institutions, territorial bodies established in accordance with the established procedure for the implementation of sanitary and epidemiological supervision, institutions of forensic medical examination, logistics services, enterprises for the production of medicines and medical equipment and others enterprises, institutions and organizations.
The state health care system includes medical organizations, including medical and preventive 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 as follows.
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 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 the 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, in case of illness, citizens had the right 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 providing full nutrition to 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 when 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 disabilities or mental development at the request of parents or persons replacing them, they can be kept 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 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 at 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 health 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 polyclinic, 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 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); 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 the manner prescribed 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.
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 emergency 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 methods diagnostics, treatment and 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.
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 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 to provide 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” was excluded 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 amendments, 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 provision 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 the types and the volume of medical care in the context of epidemics 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 as to how the Ministry of Health and social development The Russian Federation will be able to organizationally implement this control in all regions of the vast country.
Art. 59. General practitioner (family doctor) - stated as follows.
General practitioner (family doctor) - 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.
Significant 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 compliance of legislation with the existing state of affairs, i.e., the possibilities for the implementation of the law.
This article is supplemented by the following parts.
Measures of social support for medical and pharmaceutical workers of federal specialized healthcare 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 allowance.
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 one-time cash allowance in the event of the death of employees of 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.
Addressing issues of social support and social services for people with mental disorders in difficult life situation, 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 have the right to a shorter working time, 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 the event of harm to their health or death while on 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 question arises, what is the difference between working with patients mental illness in federal institutions health care 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 aged 18 years (in the old edition - up to 60 years) who has undergone a medical examination.
The article on federal programs for the development of blood donation has been excluded. 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 the 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 support 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 were 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 prescribed 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 HIV infection in the line of duty has been eliminated.
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 people, as well as persons whose work is related to 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 providing these guarantees and establishing the amount of bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of federal health care 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 bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of healthcare 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 while on 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 amended 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,
The refusal of the state to influence the social conditions of people's life, 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 lead to a worsening of 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. A separate constituent entity of the Federation, no matter how good everything is in this constituent entity (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 limit 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, a decrease in the responsibility of the state for social processes taking place in this state is a blow to the authority of the state as a whole, undermines faith in a social orientation. public 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 that 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.
The exclusion from the rights of persons under observation in connection with tuberculosis and tuberculosis patients of the right to free travel on public transport in urban and suburban traffic when they call or refer to consultations in medical anti-tuberculosis organizations is unlikely to contribute to an improvement in 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 the composition of the family, 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 queues of individual living quarters, 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 - set out in the following edition.
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 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.
The procedure for providing these guarantees and establishing the amount of bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of federal health care 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 bonuses to official salaries for work in especially hazardous to health and difficult working conditions for employees of healthcare 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 the Russian healthcare legislation 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 care 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 for the main types and volumes of medical care stipulated in the federal program.
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--PAGE_BREAK - 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 healthcare institutions is 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 health 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; contradictory legal regulation; the existence 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; problems of implementation of the legal rights of 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, they 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. It is well known that the types and volumes of medical care envisaged by the programs of state guarantees for providing citizens with free medical care exceed the financial capabilities of the budget and the funds 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 vast 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 by ... forced expenses of patients to pay for medicines and medical services ". Meanwhile, medical institutions cannot fail to fulfill the program of state guarantees, and there is no officially established mechanism for compensating for the lack of financial support for the 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 be in violation of a number of laws, including the Criminal Code. But can the institution (at least theoretically) offer the population to pay for medical services provided in excess of the scope 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 subject of the Federation, in others - at the expense of municipal (district) budgets. This and many other problems are intended to be solved by the law "On compulsory health insurance" which is being developed now.
The legal regulation of relations in the field of private medical activity cannot be considered sufficient either. Medical activity is a special type of activity with a high risk to 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. To fill these gaps, the Health and Sport Committee The State Duma a draft federal law “On the regulation of private medical activity” has been prepared.
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 to reasonable directions for the provision of paid services. This is caused primarily by the weak development of the regulatory framework for the provision of paid services in healthcare. At the same time, there is a fairly clear legal basis for the entrepreneurial activity of non-profit organizations (which include budgetary medical institutions), taxation, etc., fixed 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 approval of the rules for the provision of paid medical services to the population by medical institutions ”, without introducing anything new. It is quite obvious that these rules do not cover the entire list of issues arising from 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 20.03.92 No. 93 "An indicative list of medical services provided at the expense of state, public organizations, institutions, enterprises and other economic 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.).
2.3 Inconsistency of legal regulation of the healthcare sector
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 amounts of financing from the budgets of state extra-budgetary funds refer to earmarked receipts, that is, to incomes that are not taken into account when determining the tax base of 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, the tax authorities refuse to recognize these revenues as earmarked receipts and insist on including them in the tax base.
Unfortunately, in many respects, changes in tax legislation also have an adverse effect on the filling of regional and local budgets and, accordingly, on the financial possibilities of supporting health care. So, as a result of tax changes, the regions in recent years have lost a significant part of the income that went to 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 profit tax is directed to the budgets of the constituent entities of the Federation, and the decrease in the tax rate of the profit tax has the greatest effect on the regional budgets. As for the positive aspects of 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 directed 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 medical 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 CHI funds; executive authorities do not contribute funds for insurance of the unemployed population, etc.) 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 greatest number of disputes on economic issues are the issues of remuneration 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 of wages for employees of organizations with mixed financing (budgetary financing and income from entrepreneurial activities) is carried out in accordance with laws, other regulatory legal acts, collective agreements, agreements, local regulations organizations. Higher healthcare authorities usually interpret this article as follows: collective agreements, agreements, local regulations of medical institutions are valid if they do not contradict the current regulations and decisions of higher authorities (including 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 employees 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 non-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 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 of the Civil Code of the Russian Federation, if the medical institution is unable to repay the loan, the owner of the corresponding property shall bear subsidiary responsibility for its obligations. However, medical institutions are expanding their business activities, which is difficult to do without the use of borrowed funds. Meanwhile, it is not entirely clear whether the restriction on borrowing, introduced by the Budget Code, concerns 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 subsidization of 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 Law of the Russian Federation "On Medical Insurance of Citizens in the Russian Federation" it is written 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 wish, 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 regulatory documents and general legal principles relating to 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 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 the 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 the 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 or health authorities intervene in pricing issues.
Other issues on which medical institutions often experience unreasonable pressure from higher authorities include the level of wages 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. 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 the legal regulation of the economic aspects of the activities of medical institutions should not only be based on the fundamental principles of law, the requirements for the protection of the rights and freedoms of citizens, the observance of the interests of the state, etc., but also comply with economic laws, contribute to the effective economic activity of health care 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 the introduction of amendments to existing 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.). In addition, 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 a large role in improving the legal regulation of the economic sphere of health care.
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--PAGE_BREAK - 3. Problems government controlled 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 on a sufficient large territory; the predominance 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 early 1990s, there has been a decline in resource provision rural health care. Weak medical and diagnostic base, low material and technical equipment, low level of development information technologies- this is not a complete list state of the art 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 improving the organization of medical care for the rural population reasonably lies in the reorientation of the main efforts from the hospital stage to the outpatient one, that is, the restructuring of 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, we can conclude that the reform processes, which have been sufficiently developed at the theoretical level and reflected in the Concept for the development of health care 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, the priority development of the outpatient-polyclinic link, the redistribution of the volume of activities and resource provision between the structures of hospital, community-based, medical and social care.
One of the main directions of improving the organization of medical care is the development of primary health care (PHC). A special role in this is assigned to the development of the institute of general (family) practice (GP). The World Health Organization, which regularly publishes rankings of health systems in countries of the world, considers the main thing not 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 seek advice from more qualified, better equipped second-level specialists in a timely manner, 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 almost entirely depend 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 regulating 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 that determine 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 for their adequate equipping with medical equipment.
In the conditions of a transitional period from the service of district doctors to an AFP, 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 on initial stage the introduction of these specialists in the service area, 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 viewed 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. Basic forms independent work nurses of the OVP are home patronage of the patient, conducting classes in "schools for patients", reception at the clinic. Medical care provided by a paramedic who has a certificate of a specialist in medical care is characterized by a large amount of medical and preventive 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.
Until today, there has been no real reform of primary health care. The overwhelming majority of outpatient clinics continue to provide primary medical care by the local therapist and narrow specialists. 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.
Within the framework of restructuring and improving the efficiency of healthcare, an 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 the I and II levels (district and central regional hospitals) does not meet the requirements either in terms of capacity, or in material and technical equipment, or in 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 are hospitalized in them who need not so much intensive therapy as medical and social assistance. 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 Samara region As part of the admission department, diagnostic beds are organized 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, 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.
Taking into account 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 diagnostic assistance, and especially creation of interdistrict consultative and diagnostic centers. To increase the real role of interdistrict centers, it is necessary to determine correct forms interaction and responsibility of the administrative bodies of municipalities included in the medical and 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 larger 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 protection bodies, and public organizations.
If in our country the medical and social direction in providing assistance to the elderly rural population began to actively develop since 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-power 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 transformation, but with the preservation of 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 health care; analysis of health care management and financing systems of the constituent entities of the Federation and municipalities; establishment of 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 integration of 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 (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).
3.2 Ways of solving problems of public administration in the field of health 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 systems. Non-recognition of 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 implementation of disease prevention and 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 at 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 enshrined 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 managing 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 mandatory adoption of regulatory and individual acts of a higher-level control subsystem for its own level and lower-level subsystems should be ensured by the presence of specific measures of responsibility for non-compliance 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 self-government bodies.
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 the 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 delineating powers (decentralization) in the healthcare sector of foreign countries shows that, firstly, certain social and cultural conditions for decentralization are needed, 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 individual 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, according to 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. The 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 interconnections 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, in 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 health policy, coordinate the work of various services, control the quality of medical care, introduce standardization issues in medical activities, 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 be either 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 medical services market 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, faces 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 to consider not objects during privatization, but completely different entities, consisting of peculiar processes. When preparing a healthcare organization for privatization, it is necessary to consider its activities in a complex and to 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.
continuation
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