Problems of healthcare and ways to solve them KOLESNIKOV S.I. Deputy Chairman of the Health Protection Committee Member of the Presidium of the Russian Academy of Medical Sciences ACADEMICIAN OF THE 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 advanced 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 Russian healthcare system Per capita budget expenditures on healthcare place in the world. Per capita spending budgets on health care place in the world. In terms of efficiency of the healthcare system - 130th place (WHO) In terms of efficiency of the healthcare system - 130th place (WHO) Dissatisfaction of the population and doctors with healthcare is more than 60%. Dissatisfaction of the population and doctors with healthcare is more than 60%.

Healthcare reform is an urgent need: increasing the level of health of the nation increasing the level of 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 care system - 3 autonomous systems and different types of institutions (solved without sufficient funding). 1. There is no unified health care system - 3 autonomous systems and different types of institutions (solved without sufficient funding). 2. State guarantees and financial resources for providing free medical care are not balanced; inpatient care is mainly financed, the volume of paid services is increasing (it is not resolved and the prospects are unclear). 2. State guarantees and financial resources for providing free medical care are not balanced; inpatient care is mainly financed, the volume of paid services is increasing (it is not resolved and the prospects are unclear). 3. There is no incentive for investments and payments in healthcare for individuals and legal entities, which does not allow the legalization of payments (not resolved). 3. There is no incentive for investments and payments in healthcare for individuals and legal entities, which does not allow the legalization of payments (not resolved). Health problems:

4. Low motivation of managers and employees to improve the quality of work, and of 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 of 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 resolved). 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 resolved). 6. There is no single information space (register of insured, sick, capacity, medicines, telemedicine, etc.) - to be solved 6. There is no single information space (register of insured, sick, capacity, medicines, telemedicine, etc.) - to be decided

7. Lack of elements of professional self-regulation (not resolved) 7. Lack of elements of professional self-regulation (not resolved) 8. Public-private partnership is underdeveloped (not resolved). 8. Public-private partnership is underdeveloped (not being resolved). 9. Underdevelopment of public institutions for control over the healthcare system (solved slowly and ineffectively). 9. Underdevelopment of public institutions for control over the healthcare system (solved slowly and ineffectively). 10. The participation of citizens in maintaining their health is minimal. There is no effective system of education, propaganda and stimulation of a healthy lifestyle (it is poorly resolved). 10. The participation of citizens in maintaining their health is minimal. There is no effective system of education, propaganda and stimulation of a healthy lifestyle (it is poorly resolved). 11. Lack of real responsibility of the authorities for the state of public health. 11. Lack of real responsibility of the authorities for the state of public health.

Resource support The outdated system of personnel training, both for doctors and especially for managers (managers) working in the social sphere (who do not have a medical education), is not being addressed. The outdated system of training personnel, both doctors and especially managers (managers) working in the social sphere (who do not have a medical education) is not being resolved. There is no developed modern domestic pharmaceutical and medical industry (partially being resolved) There is no developed modern domestic pharmaceutical and medical industry (partially being resolved)

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.Increasing insurance premiums and modernizing healthcare

RESULTS OF PNP “HEALTH” An additional 825 thousand lives of citizens of the Russian Federation (0.6% of the population of the Russian Federation) were saved. But in the dynamics in improving the health status of the population of the Russian Federation has slowed down

Reasons for the slowdown in improving the health status of the population of the Russian Federation Reduction in the growth of healthcare costs in constant prices Unsatisfactory response of the healthcare system to abnormal weather and environmental conditions in the summer of 2010 Unresolved key healthcare problems

Problems that need to be solved (before the emergence of social protests) Oblige all levels of government to restore order (queues, paid services, rudeness, etc.) in medical organizations, up to and including the removal of municipal and regional level managers, managers, and doctors from their positions. Oblige all levels of government to restore order (queues, paid services, rudeness, etc.) in medical organizations, up to the removal of municipal and regional level managers, managers, and doctors from their posts. Urgently organize, instead of FAPs, equipped offices of family doctors (paramedics) to bring assistance closer to the population, allowing the circulation of drugs at these points without obtaining a pharmaceutical license. Urgently organize, instead of FAPs, equipped offices of family doctors (paramedics) to bring assistance closer to the population, allowing the circulation of drugs at 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 fund. 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 fund. Introduce social and other benefits for well-performing medical workers (bonuses, payment of utilities, wider use of honorary titles and social incentives). Introduce social and other benefits for well-performing medical workers (bonuses, payment of utilities, wider use of honorary titles and social incentives). Conduct clinical examination of the working population using city and regional medical organizations. Conduct clinical examination of the working population using city and regional medical organizations.

Key problems that need to be consistently addressed Increase in budget funding to US$ 1000 per capita per year (WHO recommendation). Do not reduce the budget component (!!!). Increase in budget funding to US$1000 per capita per year (WHO recommendation). Do not reduce the budget 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 depending on the quality of work. A sharp increase in incentive mechanisms depending on the quality of work. Create a system of training and continuous education for critically needed personnel, including managers. Create a system of training and continuous education for critically needed 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 management decisions. Training of social managers for municipalities and subjects of the Federation, competent in the field of state policy and the consequences of making management decisions. Introducing strict responsibility of regional authorities for the indicators of medical care of the population. Introducing strict responsibility of regional authorities for the indicators of medical care of the population.

17 Billion RUR Billion rub 2010 2011 2012 2013 % to 2010 % to 2011 % to Education, 451699.7 Healthcare, 343389.9 Social policy, 9 Physical culture and sports, 02967.82690.1

LAWS (AMENDMENTS) Federal Law 94 On procurement for state and municipal needs (auctions and quotations) Federal Law 217 On the creation of innovation companies in research institutes and universities for the commercialization of IP On concession agreements in Healthcare (Government Decree) Transition to Insurance Payments in the Compulsory Medical Insurance Fund, FSS and Pension Fund About self-regulatory organizations (SRO) (Unified Medical Community)

NEW LAWS, amendments () On liability insurance of medical organizations On health protection of Citizens of the Russian Federation On State. (municipal) institutions Law On Compulsory Medical Insurance On the circulation of medicines and amendments to a number of laws On special economics. zones

Interference of new laws () Federal Law 83 “On ... budgetary institutions” On the circulation of medicines On education Law “On compulsory medical insurance” (+ on drug insurance?) Laws on the distribution of powers (local self-government and subjects of the Federation) “On the fundamentals of protecting the health of citizens of the Russian Federation”

The increase in the amount of insurance premiums for compulsory medical insurance will be 2% in 2011 and 2012. 230 billion rubles per year According to the Accounts Chamber of the Russian Federation, the deficit in financial support for territorial state guarantee programs (current financing of free medical care for citizens) in 2009 alone amounted to about 385 billion rubles and, according to preliminary estimates, the situation did not improve in 2010. RISK: possible even more significant failure to fulfill 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 (proposed 5, but 10 thousand rubles are needed) Minimum insurance premiums for the non-working population (proposed 5, but 10 thousand rubles are needed) Increase in these payments by 25% annually from 2013 until 2015 An annual increase in these payments from 2013 by 25% until 2015. Decrease: Inclusion in compulsory medical insurance (without provision) of ambulances, high technologies, federal clinics and the National Health Project Inclusion in compulsory medical insurance (without provision) of ambulances, high technologies, federal clinics and the National Health Project

Article 15. Transfer of the exercise of 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 healthcare systems (with the exception of primary medical care); b) pharmaceutical activities (except for the activities of wholesale trade organizations and pharmacies of federal organizations); 1) licensing of: a) medical organizations of municipal and private health care systems (with the exception of VMP); b) pharmaceutical activities (except for the activities of wholesale trade organizations and pharmacies of federal organizations); c) trafficking in narcotic, psychotropic drugs and precursors; c) trafficking in narcotic, psychotropic drugs and precursors; 2) organizing the provision of medicines for “seven nosologies”. 2) organizing the provision of medicines for “seven nosologies”.

Article 15. Transfer of the exercise of powers of the Russian Federation to constituent entities of the Russian Federation 2. Funds for the exercise of powers transferred in accordance with Part 1 are provided in the form of subventions from the federal budget. 2. Funds for the implementation of powers transferred in accordance with Part 1 are 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 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 disease, malignant neoplasms of lymphoid, hematopoietic and related tissues, multiple sclerosis, after transplantation of organs and (or) tissues is maintained by an authorized federal organ. 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 an authorized federal body.

Article 15. Transfer of the exercise of powers of the Russian Federation to the constituent entities of the Russian Federation 7. federal authority: 7. federal authority: 2) issues methodological guidelines and instructions on the transferred powers that are mandatory for execution by the authorities of the constituent entity of the Russian Federation; 2) issues methodological guidelines and instructions on delegated powers that are mandatory for execution by the authorities of a constituent entity of the Russian Federation; 3) coordinates the appointment (dismissal) of heads of executive authorities of constituent entities of the Russian Federation exercising delegated powers; 3) coordinates the appointment (dismissal) of heads of executive authorities of constituent entities of the Russian Federation exercising delegated powers;

Article 44. Medical care for 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 those that have a prevalence of no more than 10 per population. 2. The list of orphan diseases is compiled 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 compiled by the authorized federal executive body on the basis of statistical data and is 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 support for the provision of medical care and sanatorium-resort care 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 (except for the diseases specified in paragraph 2 of part 1 of Article 15) is carried out for account of funds from the budgets of the constituent entities of the Russian Federation.

Article 74. Restrictions imposed on medical and pharmaceutical workers (“medreps”) 1. Medical workers and managers do not have the right to: 1. Health workers and managers do not have the right to: 1) accept from organizations involved in the development, production and (or) sale of medicines, medical devices, or with rights to the trade name of a medicine, drug wholesale trade organizations, pharmacy organizations, gifts, money (except for remuneration under contracts for conducting clinical studies or trials, in connection with teaching and (or) scientific activities), incl. to pay for entertainment, recreation, travel to a place of recreation, as well as to 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 medicines, medical devices, or with rights to the trade name of medicines, medicine wholesale organizations, pharmacy organizations (with the exception of remunerations under contracts for conducting clinical studies or tests, in connections with pedagogical and (or) scientific activities), incl. to pay for entertainment, recreation, travel to a place of recreation, as well as to take part in entertainment events, at the expense of companies (representatives);

Article 74. Restrictions imposed on medical and pharmaceutical workers (“medreps”) 2) enter into agreements with the company on prescribing or recommending drugs and medical devices to patients (except for clinical trials); 2) enter into agreements with the company on the prescription or recommendation of drugs and medical devices to patients (except for 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 to a patient, provide unreliable, incomplete or distorted information about the medications and medical devices used, incl. hide information about the availability of similar medicines and medical products in circulation; 4) when prescribing a course of treatment to a patient, provide unreliable, incomplete or distorted information about the medications and medical devices used, incl. hide information about the availability of similar medicines and medical products in circulation;

Article 74. Restrictions imposed on medical and pharmaceutical workers (“medreps”) 5) not to receive representatives of companies, with the exception of clinical studies and trials, to participate in the manner established by the administration of the organization, in meetings of medical workers and other events related to increasing the professional level of medical workers or providing information on side effects; 5) not to receive representatives of companies, with the exception of clinical studies and trials, to participate in the manner established by the administration of the organization, in meetings of medical workers and other events related to improving the professional level of medical workers or providing information on side effects; 6) prescribe medicines and medical devices on forms containing advertising information, 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 advertising information, 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. Pharmacists and heads of organizations: 2. Pharmacists and heads of organizations: 1) accept gifts, money, including to pay for entertainment, recreation, and also accept participation in entertainment events at the expense of the company; 1) accept gifts, money, including to pay for entertainment, recreation, as well as take part in entertainment events at the expense of the company; 2) receive from the company samples of medicines and medical devices for delivery to the public; 2) receive from the company samples of medicines and medical devices for delivery to the public; 3) enter into agreements with the company to offer certain medicines and medical products to the population; 3) enter into agreements with the company to offer certain medicines and medical products to the population; 4) provide unreliable, incomplete or distorted information about available drugs that have the same INN, medical products, including hiding information about the availability of drugs and medical products that have a lower price. 4) provide unreliable, incomplete or distorted information about available drugs that have the same INN, medical products, including hiding information about the availability of drugs and medical products that have a lower price.

Article 75. Settlement of conflicts of interest in the implementation of medical and pharmaceutical activities - 1. Conflict of interest is a situation in which a medical or pharmaceutical worker, when carrying out professional activities, has a personal interest in receiving personally or through a company representative a material benefit or other advantage that affects or may affect the proper performance of his professional duties due to a conflict between the personal interests of the medical or pharmaceutical worker and the interests of the patient. 1. Conflict of interest is a situation in which a medical or pharmaceutical worker, when carrying out his professional activities, has a personal interest in receiving personally or through a company representative a material benefit or other advantage that affects or may affect the proper performance of his professional duties due to a contradiction between personal the interests 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 about this in writing, and individual entrepreneurs - 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 about this in writing, and individual entrepreneurs - 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 pharmacy organization is obliged to notify the authorized federal executive body about this in writing within seven days. 3. The head of a medical or pharmacy organization is obliged to notify the authorized federal executive body about this in writing within seven days. 4. To resolve conflicts of interest, the authorized federal body establishes a commission to resolve conflicts of interest and approves the regulations on it. 4. To resolve conflicts of interest, the authorized federal body establishes a commission to resolve conflicts of interest and approves the regulations on it. 5. The composition of the commission must exclude the possibility of a conflict of interest that could affect the decisions made by the commission. 5. The composition of the commission must exclude the possibility of a conflict of interest that could affect the decisions made by the commission.

Deputy Chairman of the Federation Council Committee on Social Policy and Health Lyudmila Vyacheslavovna Kozlova spoke about health problems in Russia and possible methods for resolving them

“I will outline the main problems in the industry.

In March and May of this year, round tables were held in the Federation Council on import substitution of medicines and medical products. I am very grateful to those people who not only responded and took part in the event, but also made their suggestions.

Many ministries and departments are involved in ensuring the health of citizens. When we talk about this, we first of all refer to the Constitution of the Russian Federation, which states that every citizen has the right to free medical care. Now the volume of paid services is growing very much - I believe that they should exist, but as an alternative. In general, people should receive free medical care, as stated in the Constitution.

I will refer to two messages from the President of the Russian Federation. In 2013, Vladimir Putin said that in recent years we have managed to do a lot to develop healthcare. He noted an increase in life expectancy and a decrease in mortality from cardiovascular and a number of other diseases. The president’s phrase inspires optimism and allows us to conclude that at the highest level they are aware of the problems of domestic healthcare.

Let me remind you that Vladimir Putin proposed declaring 2015 the National Year of Fighting Cardiovascular Diseases. Round tables were held at the site of the Federation Council, in which Russian cardiologists participated - those doctors who have achieved high results both in science and in practice. They work well and hard, they know all the problems, but the mortality rate from this group of diseases in our country remains quite high. I note that I did not see a single pediatrician among them. We believe that the origins of all adult diseases lie in childhood and prevention should begin at an early age. And not even when the child is born, but when the family is still planning a new addition.

Problems of domestic healthcare:

. Personnel shortage. Despite the wholesale reduction that has occurred in the country, especially in the capital, this problem still exists. Under these conditions, it is impossible to talk about the availability and quality of medical care.

. Growth of paid services.

. Shortage of medicines and rising prices for them . To avoid corruption and other negative aspects, medicines should be centrally purchased and distributed. Residents of all regions of Russia should equally have the opportunity to receive them. It is known that there are subsidized entities in which it is very difficult to provide expensive drugs to everyone who needs it.

The state of the material base has improved since the launch of national projects. However, it is medical personnel that are the main and significant part of health care resources. As Vladimir Putin said: “Despite all the technical innovations in medicine, it is the personal qualities of the doctor that have always been valued.<…>We must create all conditions for them to work with dignity.”

Ways to solve problems in healthcare:

. Increasing the social status of medical workers.

. Increase in wages and base payments.

. Housing provision.

There is a well-known phrase: “Health is not everything, but without health everything is nothing.” When everyone understands this, the working conditions of doctors will improve, which will benefit the health of the population. A strong state arises only when the population is healthy.

Medical education

Another problem that exists is that, given the shortage of personnel, we must have continuous medical education. Now everything is changing very quickly, modern devices, new research and treatment methods are appearing. In conditions of personnel shortages, it is difficult to let the chief physician go for training even for 2 months. When developing distance education, it should be used for those who already have work experience and certain practical skills. In the case of graduates, it must be used very carefully.

Problems of modern medical education

We know that the quality of medical care cannot be higher than the level of education received. Therefore, medical education really deserves close attention and reform. Why have they become worse at teaching? The fact is that the social status of teachers, as well as doctors, is low. Currently there is no competition for theoretical departments.

. Integration of employees of clinical departments of medical universities into the treatment process. If the employee is not an employee of a medical institution, then this is very difficult to do. But there are solutions - in conditions of personnel shortage, the chief physician can hire an employee at half or a quarter of the rate.

. Inconsistency of the system of advanced training of medical personnel with the needs of practical healthcare and international standards.

. Issues with the clinical bases of universities and the management of employees of departments of clinical activities on the basis of state and municipal medical entities have not been resolved.

The peculiarity of our domestic medicine is its preventive focus. We know that disease is easier to prevent than to treat. Now there are various proposals - for example, to work directly with the compulsory medical insurance fund, bypassing insurance companies, etc. I believe that you need not to jump into action, but to analyze the situation and listen to all points of view.

The proposed introduction of additional state guarantees must necessarily be linked to the reciprocal obligations of citizens - maintaining a healthy lifestyle, regularly undergoing preventive examinations and following doctor’s recommendations. In my opinion, we need a federal law to stimulate motivation for a healthy lifestyle.”

"Advisor to an accountant in healthcare", 2009, N 3
CURRENT PROBLEMS OF MODERN HEALTH CARE
AND POSSIBLE WAYS TO SOLUTION THEM
Today we have to admit, alas, the imperfection of the domestic compulsory health insurance system. This article discusses the problems of guaranteeing the rights of the patient when applying to medical institutions.
To implement the priority national project “Health”, as well as the Concept of Healthcare Development until 2020, it is necessary to identify and analyze existing problems in the implementation and protection of citizens’ rights that arise in law enforcement practice, as well as take the necessary measures to improve the regulatory framework.
The Constitution of the Russian Federation guarantees every person the right to health care and medical care. At the same time, in state and municipal health care institutions, medical care is provided to citizens free of charge. In development of these provisions of the Constitution of the Russian Federation, on July 22, 1993, the Supreme Council of the Russian Federation adopted the Fundamentals of Legislation of the Russian Federation on the protection of the health of citizens (hereinafter referred to as the Fundamentals of Legislation), which stipulates that all citizens of Russia have an inalienable right to health protection. This right is ensured by providing the population with accessible medical and social assistance.
A guaranteed volume of free medical care is provided to citizens in accordance with the program of state guarantees for the provision of free medical care to citizens, which is annually approved by the Government of the Russian Federation. This program determines the types, standards for the volume of medical care, standards for financial costs per unit of volume of medical care, per capita financing standards, as well as the procedure and structure for the formation of tariffs for medical care and contains a list of types of diseases for which free medical care is guaranteed. The list of diseases is compiled on the basis of the International Statistical Classification of Diseases and Related Health Problems. Tenth revision. Geneva, 2005 (ICD-10) (approved by Order of the Ministry of Health of Russia dated May 27, 1997 N 170) and contains all types of diseases known to modern medicine, for which citizens should be provided with free medical care.
Thus, in Resolution No. 913 dated December 5, 2008, the Government of the Russian Federation established for 2009 a program of state guarantees for the provision of free medical care. In particular, the standards of financial costs per unit of volume of medical care provided are determined in the following amounts:
- for 1 emergency medical call - 1710.1 rubles. (in 2008 - 1213.3 rubles);
- for 1 bed-day in hospitals - 1380.6 rubles. (in 2008 - 758.9 rubles).
And by Letter dated December 31, 2008 N 10407-TG, the Ministry of Health and Social Development clarified some issues of the formation and economic justification of the relevant territorial state guarantee programs. Thus, to economically justify the costs of emergency medical care, it is recommended to use average indicators per resident per year: 0.96 visits, including 0.9 visits to health care institutions and 0.06 visits at home. The average estimated cost of one visit (including costs for medicines and medical products) is 323.0 rubles. (229.0 rubles - in an institution, 1169.4 rubles - at home).
The formation of market relations has confronted the state with the need to search for other sources of financing the healthcare system in addition to budgetary allocations. With the adoption on June 28, 1991 of the Law of the Russian Federation N 1499-1 “On Health Insurance in the Russian Federation” (hereinafter referred to as the Law on Health Insurance), which introduced the compulsory health insurance system, the process of direct reform of the health care system began in Russia.
The main goal of the reforms was to increase the efficiency of using available resources, improve the quality of medical care, strengthen preventive work, and eliminate the actual inequality of access to qualified medical care depending on the place of residence and income level of citizens. The social insurance system was adopted as a basis: compulsory and voluntary health insurance.
The introduction of a compulsory health insurance system was based on the main goal of obtaining additional sources of funding and improving the quality of medical care for citizens within the framework of relevant constitutional guarantees.
The implementation of insurance principles has made it possible to formulate new methods of medical and economic assessment of the medical care provided, created as a counterbalance to the traditional system of departmental control that has existed for many decades. And most importantly, a previously unknown institution of the patient’s rights as a consumer of medical care has appeared.
However, the shortcomings of the Health Insurance Law, as well as the inconsistency in its implementation, have created serious problems and undesirable trends in the healthcare sector. And law enforcement practice has shown insufficient regulation of the most important elements of the compulsory health insurance system.
Top officials are aware of the relevance and need to quickly resolve the problems of modernization and development of domestic healthcare.
On December 21, 2005, the Presidium of the Council under the President of the Russian Federation for the implementation of priority national projects approved the main activities and parameters of the priority national project "Health", which includes two main areas: "Development of primary health care" and "Providing the population with high-tech medical help."
The goal of this project is to preserve and strengthen the health of the Russian population through the formation of a healthy lifestyle and increasing the availability and quality of medical care, which, in turn, will lead to an increase in life expectancy and an increase in the birth rate in the country.
In addition, the Concept for the Development of Domestic Healthcare until 2020, developed in accordance with the message of the President of the Russian Federation, provides for mechanisms to ensure the responsibility of doctors and medical organizations for the quality and results of their work, as well as a phased transition to a full tariff for medical services and for the provision of the entire volume of medical care in within the framework of the State Guarantees Program for the provision of free medical care to citizens of the Russian Federation through the compulsory health insurance system.
Eliminating the shortcomings of the healthcare system will create additional guarantees of the rights of citizens in the field of compulsory health insurance.
Patient status
One of the main problems seems to be the regulation of the patient’s status. It is the patient who is the system-forming subject of healthcare, since all forms of activity and all possible options for relationships are formed around him.
By virtue of Art. 30 Fundamentals of Legislation, when seeking medical care and receiving it, the patient has the right:
- respectful and humane treatment on the part of medical and service personnel;
- choosing a doctor, taking into account his consent, as well as choosing a medical institution in accordance with compulsory and voluntary health insurance contracts;
- examination, treatment and maintenance in conditions that meet sanitary and hygienic requirements; relief of pain associated with disease and/or medical intervention, and much more.
A sick person is a person with a weakened ability to fight for the observance and protection of his rights. In a difficult life situation, his only goal is a speedy recovery, and the issue of protecting violated rights fades into the background. It is for this reason that protection is necessary, as well as more detailed regulation enshrined in Art. 30 Fundamentals of legislation on patient rights. Today, at different levels of government, there are officials whose direct responsibility is to directly monitor the observance of the rights of citizens (including patients), and in case of violation of these rights, to protect their interests. First of all, these are officials of medical organizations, health care and health insurance authorities. However, the presence of gaps in legislation makes such assistance less effective.
Citizens' lack of awareness of their rights
Practice shows that in most cases, patients who seek medical care at state or municipal health care institutions do not really know what compulsory health insurance is and what rights they have as insured persons, what services should be provided to them free of charge, and which ones need to be paid for.
This problem is due to the complexity of the system of relations and the relative novelty of the institution of compulsory health insurance. And the division of powers in the field of health care between the Russian Federation, its constituent entities and local governments and, accordingly, sources of funding further complicates the Russian healthcare system.
The patient receives primary care based on the definition at the place of first contact with a medical professional: most often these are doctors of municipal clinics or ambulances. If there is a need for medical care that requires special diagnostic and treatment methods, the patient is provided with specialized care in a clinic or hospital setting. However, the disunity in the activities of health care systems, including the “division” of funding by levels, creates difficulties in treating patients, the impossibility of complying with the requirements of phasing and continuity in the implementation of the diagnostic and treatment process.
In conditions of obvious insufficiency of sources for the formation of the municipal budget, the municipal health care system is extremely financially unstable and dependent on the budget of the constituent entity of the Russian Federation. The state authorities of the constituent entity of the Russian Federation, being interested in the development and financing of their health care institutions, shift responsibility for financing municipal health care institutions to local governments. All this leads to a low level of provision of primary health care to the population.
In our opinion, only the development of a radically new concept and methodology for compiling a list of paid and free social resources provided to the population will help solve this problem.
Multi-stage control
Disunity in the management of the health care system also creates significant difficulties. The legislative division of the country's healthcare system into state, municipal and private, as well as the provision of a wide range of powers to the constituent entities of the Russian Federation in this area leads to disunity and uncontrollability in healthcare. In addition, the division of powers between the Federation and the constituent entities means the adoption by each constituent entity of the Russian Federation of an independent territorial program of state guarantees for the provision of free medical care for a year.
Of course, the absence of a unified program of state guarantees operating throughout the entire territory of the Russian Federation, as well as the lack of actual unity of the healthcare system, negatively affect the awareness of citizens about the rights granted to them in the field of compulsory health insurance.
Liability Insurance
One cannot fail to note another important problem - the lack of compulsory professional liability insurance for medical workers.
One of the characteristic features of medical activity is a high degree of risk and the unambiguous unpredictability of medical effects. In the context of an increasing number of claims from patients related to compensation for harm caused to them during medical intervention, as well as an increase in the amount of required compensation, there is an urgent need for civil liability insurance related to professional medical activities.
Clause 7 of Art. 63 of the Fundamentals of Legislation provides for the right of medical and pharmaceutical workers to insurance for a professional error, as a result of which harm or damage to the health of a citizen is caused, not related to the careless or negligent performance of their professional duties.
Unfortunately, this norm has not received further development either in the legislation on the protection of public health or in by-laws.
However, it is worth noting that the lack of industry legislation is not an insurmountable obstacle to the introduction of civil liability insurance into medical practice, since this type of insurance is nothing more than one of the special cases of liability insurance for causing harm, regulated in sufficient detail by Chapter. 48 of the Civil Code of the Russian Federation, Law of the Russian Federation of November 27, 1992 N 4015-1 “On the organization of insurance business in the Russian Federation,” etc.
Civil liability insurance is aimed primarily at the financial protection of victims. For a patient who has suffered harm to his health or life as a result of a medical intervention, it is important not to punish the medical worker, but to find a means of livelihood, since often due to an error, loss of ability to work occurs. Therefore, civil liability insurance of medical organizations and payment of insurance compensation to victims are aimed not so much at protecting medical workers, but at ensuring the property interests of patients who can count on quickly receiving material compensation from the funds of insurance companies.
Today, the established legal framework for civil liability insurance related to professional medical activities is quite sufficient. So now everything depends on the desires of the medical organizations themselves and the economic interests of insurance companies.
Consumer protection
Part 2 Art. 30 of the Fundamentals of Legislation provides for the patient’s right, in the event of a violation of his rights, to file a complaint directly with the head or other official of the medical institution in which he is receiving medical care, with the relevant professional medical associations or with the court.
Issues of protection and restoration of violated rights of patients are regulated by other laws, including the Law of the Russian Federation of July 2, 1992 N 3185-1 “On psychiatric care and guarantees of the rights of citizens during its provision”, Federal Law of March 30, 1995 N 38-FZ “On preventing the spread in the Russian Federation of the disease caused by the human immunodeficiency virus (HIV infection)."
In all of these regulatory legal acts, the patient is assigned the right to appeal against unlawful actions or inaction of employees of medical institutions. The procedural procedure for protecting the rights of the patient is provided for by the current Civil Procedure and Criminal Procedure Codes. However, it is worth noting that the specifics of the procedure for exercising this patient’s right are not regulated by domestic legislation.
Quality of medical services
No less a problem is the lack of regulations at the federal level for assessing and monitoring the quality of medical services provided. Currently, there is no single federal act that describes the concept and content of the quality of medical services. This leads to the fact that in practice the patient is not able to assess the quality of the care provided to him.
However, in Art. 6 of Law N 1499-1 provides for the right of citizens to receive medical services that correspond in volume and quality to the terms of the health insurance contract. A Art. 27 of this Law establishes the responsibility of medical institutions for the volume and quality of medical services provided and for refusal to provide medical care to the insured party.
Thus, the concept of “quality of medical services” is determined only by an agreement between the parties (between the insured and the policyholder, between the insured and the medical institution), while it “deserves” public legal recognition.
In our opinion, it is necessary to introduce a new approach to solving this issue, namely, at the federal level, to detail what is included in the concept of quality medical services, as well as to create an independent expert commission under the territorial compulsory health insurance fund.
Despite the fact that this issue is regulated by FFOMS Order No. 111 dated May 26, 2008 “On organizing control over the volume and quality of medical care in the implementation of compulsory health insurance,” at the same time it requires significant refinement as part of improving the legislation on compulsory health insurance.
Lack of a special institution
pre-trial dispute resolution
In practice today, disputes arise between patients, medical institutions and insurance organizations on issues related to the provision of medical care. These disagreements have to be resolved in a court of general jurisdiction, which, in addition to this category of cases, considers disputes arising in all areas of domestic legislation. A judge must understand all the intricacies and features of each branch of law, which is impossible for objective reasons.
Therefore, there is a need to create an independent institution that would be able to consider and resolve disputes in such a specific area. Therefore, it seems necessary to create a medical insurance arbitration court under the territorial compulsory health insurance funds.
Thus, in order to systematically improve the healthcare system and implement the tasks set in the recently adopted Concept for the development of healthcare in the Russian Federation until 2020, it is necessary to fully ensure the implementation and protection of citizens’ rights in this area.
Material prepared
specialists
Center for Accounting Methodology
and taxation
Signed for seal
25.03.2009

The transition from the paternalistic (total guardianship) system of the Soviet state to a liberal model in the healthcare sector had negative consequences. The changes had a very negative impact on the health of Russians - it became worse compared to the Soviet period. In recent years, a vicious circle has emerged in which domestic healthcare finds itself: the more funds are invested directly in medicine (in specialized hospital care and high technologies), the less funds remain for prevention and early detection of diseases. The lack of prevention predetermines an increase in the number of patients, the detection of diseases in later stages, and the chronicization of pathologies. This in turn requires even greater investments. This leads to a number of complex social problems in Russian healthcare:

The transition from mass recreational and preventive measures to individual treatment, i.e. dominance of clinical medicine;

Increasing the cost of healthcare does not improve its effectiveness;

Increasing medical fees, constant shortage of funds, opacity of financial flows;

Deformation of humanism and medical ethics, which now allows us to see the patient as another source of income;

The sharp economic stratification of Russians, which predetermines unequal attitudes towards health and opportunities for receiving medical care;

Inequality in the income of doctors themselves;

Shifting responsibility for health only to the population itself.

The main negative consequence of these problems is an unprecedented reduction in population in peacetime. Today this is no longer such a devastating process as it was in the previous 18 years. There are trends towards stabilization in numbers, but the “quality” of people’s health, habitat degradation, and a critical decline in the country’s labor and defense potential are current threats. The demographic situation in the Russian Federation is still unfavorable, although the rate of population decline in recent years has decreased significantly - from 700 thousand people annually in 2000-2005 to 213 thousand in 2007. In 2008, the rate of natural population decline was 2.7 per 1000 population. As of 2010, the resident population in the Russian Federation was 141.9 million people. The slowdown in the rate of population decline is mainly due to the birth rate and the decrease in mortality. In 2007, 8.3% more babies were born than in 2006 (1 million 602 thousand). In 2006, for the first time in 7 years, life expectancy began to increase - from 65.3 years to 67.5 years. However, the average life expectancy in Russia is 6.5 years less than that of the “Young Europeans” (countries that have joined the EU since 2004) and 12.5 years less than in the countries of “Old Europe”. A large difference in Russia remains in the life expectancy of men and women – 13 years. The main reason for this is the high mortality rate of men of working age. Life expectancy is a generally accepted indicator of quality of life and health and a correct measure of the mortality rate. The main causes of death in Russia are:

Circulatory diseases, from which, for example, about 1.2 million people died in 2007 (56.6% of deaths);

Neoplasms (13.8%)

External reasons (11.9%).

It is very significant that cancer

in Russia are characterized by a high proportion of deaths during the first year after diagnosis: for example, the percentage of deaths from lung cancer is 56, from stomach cancer - 55. This suggests that people go to the doctor late, when treatment is very expensive, and the risks of fatal outcomes great. Men of working age die from cancer 2 times more often than women, although the incidence among women is higher.

In Russia, mortality from external causes is 4.6 times higher than in the countries of old Europe and 2.6 times higher than in the “new” ones. These reasons are mainly:

Excessive consumption of strong alcoholic beverages;

Road accidents;

Suicides.

The most important indicator of the effectiveness of healthcare in any country is the average life expectancy of people suffering from chronic diseases. In Russia it is 12 years, in EU countries – 18-20 years. Disability in the Russian Federation has not decreased, including among those of working age; there are 14 million of them in the country, of which 523 thousand are children. This indicates the low quality of medical care and inadequate social rehabilitation.

The percentage of risk factors (high blood pressure, high cholesterol, smoking, alcoholism) in the structure of mortality among Russians is 87.5%. The first place among these factors is excessive alcohol consumption. This is the country's most important public health problem. Every day in Russia, 33% of boys and 20% of girls, about 70% of men and 47% of women drink alcoholic beverages (including low-alcohol drinks).

In 2006, the priority national project “Health” was launched with four main directions:

Development of primary health care;

Strengthening preventive activities;

Increasing the availability of high-tech assistance;

Introduction of the birth certificate system.

In 2007, a pilot project to modernize healthcare was carried out in 19 regions of the Russian Federation. In 2008 programs began to improve care for patients with cardiovascular diseases, victims of road accidents and a program to develop blood services. In 2009, programs were launched to improve the organization of cancer care to the population and activities aimed at creating a healthy lifestyle.

As a result of three years of project implementation efforts, demographic and health indicators improved:

The birth rate increased by approximately 16%;

Life expectancy increased by 2.2 years;

The overall mortality rate decreased by 10%.

State intervention, increased funding, and finally, personal control of top officials in this situation can be converted into a figure of 500 thousand saved lives of Russian citizens.

What systemic problems await Russian society and healthcare in the near future? Firstly, demographic: the share of the elderly population in the Russian Federation will increase from 21% to 28%; secondly, a decrease in the birth rate due to a decrease in the number of women of childbearing age. Today, girls 10-14 years old, future mothers, are 2 times less than women of childbearing age. Finally, the increase in the prevalence of non-communicable socially determined diseases. The necessary response to these challenges should be investments in the development of pediatrics and neonatology and an increase in the retirement age by 10 years. The first provision requires only financing. The second cannot be implemented immediately, since according to Rosstat, only 48% of men in our country survive to 65 years of age. It is necessary to extend the life expectancy of men by at least another 5 years and then it will be possible to discuss the issue of extending the retirement age.

Two serious government documents were approved by the President and the Government of the Russian Federation - “The Concept of the Demographic Policy of the Russian Federation for the Period until 2025” and “The Concept of Long-Term Social and Economic Development of the Russian Federation for the Period until 2020.” The latest document applies to all industries, including healthcare. It sets goals: to reduce the mortality rate by 1.5 times by 2020 and increase life expectancy to 73 years. The main principles of this strategy should obviously be:

Solidarity (the rich pay for the poor, the healthy for the sick);

Equality between urban and rural residents, rich regions and depressed ones;

Pluralism of opinions, openness and evidence-based decision-making;

No corruption.

The main direction of this strategy is the adaptation of the Semashkov system of organizing medical care to modern conditions and increasing management efficiency. To solve these types of problems, the object of research should be health at the national level. The efforts of sociology, medicine, hygiene, and management economics will help determine trends in the health of individual regions and the country as a whole. In order to build an effective social policy to optimize the health of various groups of people, it is necessary to differentiate and determine the significance of the influence of the environment, lifestyle, and biological factors.

QUESTIONS AND TASKS.

1. What is the difference between the concepts of “health” and “public health”?

2. What parameters determine a person’s health?

3. List the main actors in the healthcare system.

4. Name the main problems of healthcare in the Russian Federation.

5. How do the social role and status of a medical worker correlate with his social prestige?

6. How do ecosystem states relate to human health?

7. Which lifestyle elements have the most noticeable positive and which negative effects on human health?

8. What are the main ways to solve social health problems in Russia?

9. In accordance with the Constitution of the Russian Federation, citizens are provided with medical care by state, private and municipal medical institutions. What, in your opinion, should be the ratio of these types of institutions? What are the advantages and disadvantages of each of them?

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1. Concept and history of the formation of healthcare in Russia

1.1 Concept of healthcare

2. Analysis of the national project to improve management in healthcare

2.1 New in Russian legislation in the field of healthcare

2.3 Inconsistency of legal regulation of the healthcare sector

3. Problems of public administration in the field of healthcare and ways to solve them

3.1 Problems of improving the organization of medical care to the population

3.2 Ways to solve problems of public administration in the field of healthcare

Conclusion

Introduction

Relevance of the topic. Analysis of literature data allows us to state that one of the main directions of healthcare development is to improve the organization of medical care to the population.

During the period of further transition to the market, the role of standardization especially increases as the most important tool for protecting the rights of patients. Standardization should be used by the state as an effective lever of influence on healthcare organizations, ensuring that they comply with safety requirements. The role of standardization as a means of managing medical care and increasing the competitiveness of medical services remains relevant. But the implementation of the Russian Federation Law “On Standardization” in healthcare requires not only the creation of a unified healthcare system, but also the elimination of a number of serious gaps in the legislation.

Since healthcare is a special area of ​​state activity to ensure the right of citizens to life and health, strengthening the role of law, including medical law, in the life of society, especially in the context of reforms, becomes important. Today, one should take into account the fact that on a number of issues regarding the protection of the health of citizens of the Russian Federation, laws and other regulations at the federal level and especially in the regions, if they exist, are largely outdated and require their repeal or revision and modification. In international law, the human right to health is recognized by the Universal Declaration of Human Rights: “Everyone has the right to such a standard of living... and medical care... as is necessary for his own health and well-being.”

The International Covenant on Economic, Social and Cultural Rights 1966 recognizes the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

With regard to the population of the Russian Federation, the Russian Constitution of 1993 enshrined the right of everyone to health care and free medical care. The most important legal act, which served as the foundation for the creation of an independent division of the legal system - the branch of medical law, was the Fundamentals of the Legislation of the Russian Federation on the protection of the health of citizens adopted in 1993.

A significant problem at present is that the legislation regulating medical law and declaring the diversity of healthcare does not create organizational unity of all parts of the healthcare system, which does not contribute to the establishment of uniform standards in all areas of public health activities.

In recent years, the health status of the population has deteriorated. The crisis in the activities of medical institutions is approaching the point followed by the collapse of the entire healthcare system.

The amount of healthcare financing from budgets at all levels and from compulsory health insurance does not provide the population with free medical services. At the same time, available financial and material resources are used ineffectively, and disparities in the provision of medical care are increasing. Social tension is growing in the industry. The shadow side of payment for medical services is becoming increasingly widespread.

In this regard, a well-thought-out strategy for health care reform is needed.

As a result, the implementation of norms relating to the protection of citizens' health in practice in the legal field of activity of the executive authorities of the Russian Federation, both at the federal and regional levels, leaves much to be desired. On a number of issues related to the protection of the health of citizens of the Russian Federation, there are no laws or are under development, while blind copying of elements of health care models of foreign countries, implemented in the form of experiments in certain territories, has neither a systematic nature nor a legal basis, and does not always take into account the traditions of the domestic healthcare.

The healthcare reforms carried out in the Russian Federation are clearly fragmented due to the vagueness of the legal regulation of healthcare at different levels of management, the uncertainty of the division of responsibilities of participants in the healthcare system and the coordination of their activities.

The object of the study is the relationships arising in the field of healthcare.

The subject of the study is the basics of management in the healthcare sector.

The purpose of the work is to explore the regulatory framework and organization of the activities of healthcare institutions and, based on the data obtained, to study the basics of public administration in the field of healthcare.

The objectives of the work are to consider the concept and history of the formation of healthcare in the Russian Federation; analyze a national project to improve healthcare management; study the problems of public administration in the field of healthcare and propose ways to solve them.

Methodology and research methods. The methodological and theoretical basis of the research is the dialectical method of cognition, logical, comparative legal, concrete sociological, systemic functional and other particular methods of research work.

1. The concept and history of the formation of healthcare in the Russian Federation 1.1 The concept of healthcare

The concept of “healthcare” means activities to preserve, improve, ensure and strengthen the health of various population groups. The main legislative acts enshrine the human right to protection and promotion of health. Optimization of the healthcare system is the most important part of the state’s socio-economic policy. Healthcare is considered as a state system with unity of goals, interaction and continuity of services (therapeutic and preventive), universal availability of qualified medical care, and a real humanistic orientation.

The priority structural element of the healthcare system is the preventive activities 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 healthcare at the present stage is the protection of motherhood and childhood, the creation of optimal socio-economic, legal and medical-social conditions for improving the health of women and children, family planning, and solving medical and demographic problems.

The public nature of health care ensures 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 unity of medical science and practice is implemented in the form of joint activities and the introduction of scientific developments in healthcare institutions.

The most important theoretical problems of health care include: the social conditionality 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 development of health care under various socio-economic conditions and etc.

The World Health Organization has defined 4 categories of general indicators that characterize the state of health care in a 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 development of healthcare in Russia

End of the 17th - beginning of the 18th century. became a significant time in the history of Russia. The reforms of the outstanding statesman and commander, the talented and energetic Peter I, made it possible to overcome the cultural self-isolation of Russia (which, however, was never absolute), to open a “window to Europe,” to establish contacts and mutual exchange, and to join the pan-European culture and civilization. Peter's reforms, the tension of the people's forces, and the work of all of Russia helped in many ways to eliminate the backwardness of the state and 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 its strength in struggles, matured with the genius of Peter”1. Russian medicine also matured, gained strength and experience.

Peter I was an educated man who highly valued science. According to the famous historian V. O. Klyuchevsky, he was imbued with faith “in the miraculous power of education” and “the reverent cult of science”2. What is especially characteristic is that Tsar Peter, according to his contemporaries, had a genuine passion for medicine. When in 1697, as part of the Great Embassy, ​​under the name of Sergeant Peter Mikhailov, he visited Holland and England, he became acquainted with medical clinics and anatomical laboratories there.

They say that Peter listened to lectures by professor of anatomy Ruysch, was present during operations, and when he saw in his anatomical office the perfectly dissected corpse of a child who was smiling as if alive, he could not resist kissing him (later Peter bought the anatomical collection of Professor Ruysch, it was located 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 tsar, arrived on his ship. The Dutch scientist “had the honor, in addition to his other rare discoveries, of showing the sovereign, to his great pleasure, the amazing circulation of blood in the tail of the eel with the help of his special magnifying glasses; Thus, two hours passed in various observations, and, leaving, the king shook Leeuwenhoek’s hand and expressed special gratitude to him for giving him the opportunity to see such unusually small objects.”3

There is a legend that in Leiden he looked into the anatomical theater to the famous Professor Boerhaave, 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 spirits.” " By the way, noticing that some of the retinue accompanying him expressed disgust at the dead body, Peter became very angry and forced them to tear the muscles of the corpse with their teeth.

“The spread of medicine in our fatherland under Peter the Great was greatly facilitated by this monarch’s passion for anatomy and surgery,” medical historian N. Kupriyanov later noted. - ...The emperor acquired a lot of knowledge and even practical skill in surgery. The monarch usually carried two sets with him: one with mathematical instruments, the other with surgical instruments, and he loved surgery so much that, under the leadership of Thurmont (this surgeon came to Russia during the reign of Tsar Alexei Mikhailovich - MM), he methodically opened up corpses, made incisions, and bled , bandaged wounds and pulled teeth. The king ordered that every more interesting operation performed in a hospital or private home be reported. The monarch not only monitored the operations, but also carried them out himself.”

A skilled craftsman, Peter knew many crafts perfectly. Success in this instilled in him a strong confidence in the dexterity of his hands: he really considered himself both an experienced surgeon and a good dentist. It happened that close people who suffered from some illness that required surgical help were horrified at the thought that the tsar might find out about their illness and, appearing with instruments (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: it was, of course, impossible to refuse the Tsar, but it was also impossible to trust him as an operator, as a doctor, as a healer. Still, as they say, he left behind a whole bag of teeth he pulled out - a monument to his dental practice.

During the reign of Peter I, which essentially opened the history of Russia in the 18th century, the distinctive feature of the organization of medical affairs in the country continued to be the state character. Despite the difficulties associated with carrying out large-scale reforms, the state sought to take care of the health of its citizens, especially the military, spending certain amounts from the budget on this 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), St. Petersburg (1716), Kronstadt (1720), Revel (1720), Kazan (1722), Astrakhan (1725) and other cities of the country . By decree of Peter I (1721), the magistrates obliged to build “the zemstvo hospitals for the sake of charity for the orphaned, sick and crippled and for the elderly people of both sexes”: as a result, during his lifetime, 10 hospitals and over 500 infirmaries were created in the country. When laying the foundation for a naval (Admiralty) hospital in St. Petersburg, on the Vyborg side, in 1715, Peter I said: “Here the exhausted will find help and reassurance, which he had hitherto lacked; God only grant that many will never have to be brought here!”

It should be emphasized that it was Peter I who provided state support for the measures taken by the Orthodox Church and many of its monasteries to combat “foundlings” and to care for orphans and illegitimate children; He especially actively supported the initiatives of the Novgorod Metropolitan Job. Back in 1706, Metropolitan Job, using 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 foundlings.” An entire monastery in Kolmovo was allocated for this “house of foundlings.” A. Gorchakov in his book “Monastic Order” (1863) reports that Metropolitan Job in 1714 had “10 hospices, 15 beggars or hospitals and a foundling house.”

Peter often cited the highly useful activity of Metropolitan Job as an example not only to the hierarchs of the Church, but also to his immediate circle: Christian charity became an important state matter. Moreover, in a decree of January 16, 1712, Peter I directly ordered: “In all provinces, hospitals should be established for the disabled, as well as non-visual reception and feeding of infants who were born from illegitimate wives, following the example of the Novgorod bishop.”

Another royal decree emphasized: “Just as the most reverend Job, Metropolitan of Novgorod, carried out a divinely thorough and soul-saving examination of the same matters in Veliky Novgorod, to choose skilled wives for the preservation of shameful babies, whom wives and girls give birth to unlawfully... Announce the decree so that such babies are not taken to indecent places..."

Even in the notebooks of Peter I there are notes indicating that he paid great attention to these endeavors. Here, for example, is a note made by Peter I at one of the meetings in the Senate:

“Was it done according to the decree on raising babies, like the Novgorod bishop Job had? And if not done, why?

Developing medicine required expanding the supply of medicines to the population. Therefore, much attention was paid to increasing the number of pharmacies. In St. Petersburg, Kazan, Glukhov, Riga and Revel, state-owned pharmacies were opened in 1706, and garrison pharmacies were opened in some other cities. At the same time, measures were taken to encourage the creation of free (private) pharmacies.

In 1701, a decree followed that every Russian or foreigner who wishes to open a free pharmacy with the permission of the government will receive the financially necessary place for this and a letter of grant for the hereditary transfer of his establishment; such pharmacists were given the right to freely prescribe all the necessary materials from abroad. In Moscow, in addition to the two state-owned ones, eight more pharmacies were allowed to open. And from 1721, free pharmacies began to open in St. Petersburg and other provincial cities. It is characteristic that both permission to open pharmacies and control over their activities were within the sphere of state interests. State medicine, primarily the military medical service, needed more and more doctors. At first they were recruited abroad. For example, only in 1698 in Amsterdam, along with captains, gunners, navigators and other specialists, 52 doctors were hired to serve in the newly created Russian fleet: each was entitled to a salary of 12 efimki, 13 altyn and 2 money per month10. All these doctors studied medicine not at universities, but through individual apprenticeship with other, more experienced doctors, and then served in the troops or on ships of various European states.

In order to find our own, more qualified doctors, it was necessary to train our 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 both therapy and surgery, were sent primarily to the army and navy.

It is generally accepted that economic progress and associated political and cultural transformations inevitably determine the need for rapid development of science. This was the case in our country.

Already at the beginning of the 18th century. In Russia, a school of mathematical and navigational sciences appeared (1701), artillery schools (1701), an engineering school (1713), a naval academy (1713), mining vocational schools (1719) and a number of others: the St. Petersburg Academy of Sciences was created (1725), and then and Moscow University (1755). Among the first in Russia, a medical-surgical (hospital) school was opened that trained doctors.

It is important to emphasize that this school was a fundamentally new type of higher medical educational institution. The main thing is that, unlike what existed in the 17th century. medical school of the Apothecary Order, which was discussed above, both the first and all other Russian medical-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., teaching) hospitals pursued a dual goal - treating patients and teaching medicine. “The establishment of hospitals has a twofold intention and fruit,” legitimized the “General Regulations on Hospitals,” approved in 1735: the first and which has the highest priority is the use of suffering patients, the second is the production and establishment of doctors and healers to great art; For this purpose, although at the beginning, it is necessary to have doctors and healers.”

The hospital schools created in Russia were fundamentally different from the medical educational institutions that existed in Western Europe - medical faculties of universities. As is known, their graduates - therapeutic doctors - received predominantly theoretical education. In contrast, surgeons who did not have a university medical education received practical training using the “trade apprenticeship” method and were considered second-class physicians. However, life showed - and at the beginning of the 18th century. it became increasingly clear that doctors needed to 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 both surgery and internal medicine. Higher medical education began in Moscow.

On May 25, 1706, a decree of Peter I was published on the organization of the Moscow “Hoffspital”: it was to be built “beyond the Yauza River, opposite the German Settlement, in a decent place... for the treatment of sick people.” The decree emphasized: “And for that treatment there will be Dr. Nikolai Bidloo, and two doctors Andrei Repken, and another who will be sent; yes, recruit 50 people from foreigners and Russians from all ranks for pharmaceutical (i.e. medical - M.M.) science; and for the building and for the purchase of medicines, and for all sorts of things belonging to that matter, keep the money for the doctor, and the doctors, and the students as a salary from the collections of the Monastic Order.”

Initially, several wooden two-story outbuildings were built for the hospital - as they were called then, “houses with light rooms.” The hospital buildings were surrounded by a garden in which medicinal plants were grown.

On November 21, 1707, the hospital was opened, and patients began to be admitted here for treatment. “Most merciful sovereign,” wrote Doctor Bidloo, who headed the hospital, to Peter I, “your royal majesty was pleased to command the construction of a hospital at Yauza, which, with God’s blessing, was under the care of His Excellency Count Musin-Pushkin (at that time the manager of the Monastic Prikaz. - M.M.) November 21, 1707, he was brought into such a state that a beginning was made with him in God’s name, and for the first time several sick people were brought into that house.”

At the same time, the first Moscow hospital (medical-surgical) school in the country began to operate, and its first students began classes. For the maintenance of the hospital and school, the Monastic Order (and then the Holy Synod that replaced it) spent part of the funds received by the clergy from monastic estates, from fees from “crown memorials” (they were paid upon marriage), from “infirmary money” (a kind of tax on medicines collected from all civil servants), from “fine money” (for overdue spiritual confession for more than a year).

To study at school, knowledge of the Latin language was required - teaching was conducted in this traditional international language of science, so the school was initially attended by 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 townspeople and artisans, from Cossacks and soldiers; There were also children of doctors among them. The majority were “natural Russians,” but there were also children of foreigners. Forced to achieve everything with their own labor, they looked at learning as work and, for the most part, engaged in it with great willingness.

However, not all of those who entered the Moscow Hospital School completed the full course of training. So, in 1712, Doctor Bidloo wrote to Peter I: “In different years and dates, I took 50 people before the science of surgery, of whom 33 remained, 6 died, 8 ran away (from schools then, as V.O. Klyuchevsky wrote, a lot ran away many young people. - MM), 2 were taken to school by decree, 1 was sent to the soldiers for intemperance.” Based on age, duration of schooling and academic success, all students were divided into three articles (categories) - first, second and third. All of them studied for free and were on full board from 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, the uniform was provided with cloth for a caftan, camisole and trousers - 7 arshins each for two years: the quality of the cloth issued depended on the article in which the student was a member.

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 introduction to the subjects that then formed the basis of medical-surgical education. These were, firstly, anatomy, secondly, “materia medica”, which included pharmacognosy (systematic botany), pharmacology and pharmacy, thirdly, internal diseases and, fourthly, surgery with desmurgy.

Anatomy, the most important discipline in medical education at that time, 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, was at one time the physician of the English king, and then a professor and rector of the famous Leiden-Batavian Academy. Nikolai Bidloo graduated from this academy, defended his dissertation on the topic “On the delay of menstruation” in 1697, and until 1702 he practiced medicine in Amsterdam. The Russian envoy to Holland, Count A.A. Matveev, on orders from St. Petersburg, invited Bidloo to Russia as Peter I’s personal physician and concluded a corresponding contract with him. In 1702, Bidloo came to Russia, which became his second home: he lived here for more than 30 years and died in Moscow in 1735.

For several years, Bidloo was Peter I's personal physician: his duties included constantly accompanying the Tsar on his extremely frequent trips around 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, published court chronicles, etc. Among the important news from Moscow, “European Rumor” included a message that “an anatomical theater was built in Moscow, which was entrusted to the supervision of Dr. Bidloo, a Dutchman and the royal physician; he often anatomizes the bodies of both those who died an ordinary death and those who died from wounds, and the king himself is often present with nobles, especially when doctors consult about the properties of the body and the causes of various diseases.”

However, numerous responsibilities began to burden Bidloo, and he turned to the king who favored him, who, moreover, due to health reasons, did not then need the services of a life physician, with a request to give him another service. So Bidloo became the chief doctor of the Moscow hospital and the director of the hospital school, where he taught anatomy and other basic subjects.

Particular attention was paid to the study of anatomy at the Moscow Hospital School: knowledge of this science was mandatory for surgeons. “Surgery,” Dr. Bidloo taught future doctors, “is treated so that the surgeon knows: 1. Anatomy, which is knowledge of the whole human body from the outside and from the inside”17. A similar anatomical (and subsequently anatomical-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 of the 18th-19th centuries.

The discipline “materia medica” (or, in other words, pharmaceutical science) was taught to hospital school students by hospital pharmacists Christian Eichler, and then Ivan Maak. The hospital had its own garden of medicinal plants (the so-called apothecary garden): in the summer and autumn, students, together with the pharmacist, went out of town, to the outskirts of Moscow, to collect medicinal plants and replenish the hospital pharmacy.

Since medical practice was then dominated by complex medicines - tinctures, elixirs, decoctions - made from many different ingredients (sometimes 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 of ​​the then known pharmacopoeias, especially the so-called London one. Along with medicinal plants, students were taught to use for treatment such exotic but commonly used medicines as dog and fox fat, wolf teeth, deer antler, hare's ankles, etc.

Internal medicine (or simply medicine) included special pathology and therapy. Their study was introduced on the initiative of Dr. Bidloo.

Surgery was taught to the students of the hospital school by Bidloo himself - only desmurgy (“institution of bandages”) was taught by his assistant, doctor Repken, and under-medicine Fyodor Bogdanov.

Thus, the training program for future doctors at the Moscow Hospital School was very rich, in no way inferior, and in some ways superior to the programs of the medical faculties of the then Western European universities, most of which were still dominated by the deadening spirit of medieval scholasticism. The main thing, of course, was the practical training of future doctors, teaching students at the patient’s bedside, in the hospital ward.

The glorious time of reforms of Peter I had a beneficial effect on Russian medicine. As a matter of fact, Russian medicine owes much to Peter I for the fact that in the 18th century. it developed basically like the medicine of 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, the 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 opened, and in 1755, the country's first Moscow University with a medical faculty was created.

An outstanding contribution to health care was made by M. V. Lomonosov, who in his work “The Word on the Reproduction and Preservation of the Russian People” gave an in-depth analysis of health care and proposed a number of specific 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. Mudrov, I. E. Dyadkovsky) . N.I. Pirogov created topographic anatomy and military field surgery, in which he put forward the position on the importance of organizing medical care during combat operations and emphasized the exceptionally high role of preventive medicine. N.I. Pirogov was the first in the world to use ethyl ether for anesthesia in military field conditions (1847), developed many methods of surgical treatment, which are still classical today, and was the first in the country to use female labor in war (1853).

2. Analysis of the national project to improve management in healthcare 2.1 New in Russian legislation in the field of healthcare

From 01.01.05, the Federal Law “On Amendments to Legislative Acts of the Russian Federation and the Revocation 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 executive bodies of state power of the constituent entities of the Russian Federation" and "On the general principles of the organization of local self-government in the Russian Federation" dated August 22, 2004 No. 122-FZ. In accordance with this law, changes were made to 196 legislative acts, including 10 federal laws in the field of protecting citizens' health.

The bulk of the amendments were made with the aim of delineating powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local governments, which radically changed the entire system of interbudgetary financial relations within the Federation, including health care financing.

In accordance with Art. 35 of the new law amends 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 healthcare system are declared invalid. Also excluded from the Fundamentals are the powers to determine the share of healthcare costs in the formation of the federal budget, trust funds intended to protect the health of citizens, and the determination of tax policy (including benefits on taxes, fees and other payments to the budget) in the field of health protection. 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 range of specialties in healthcare are supplemented by the powers to determine the range of organizations in healthcare. 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 are excluded. These and all subsequent exceptions from 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 separation 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 a rule of law state with a socially oriented market economy" (preamble to the law).

In our opinion, the powers of federal government bodies have been completely justified in issuing permits for the use of new methods of prevention, diagnosis and treatment, and new medical technologies in the territories of constituent entities of the Russian Federation. Previously, these powers belonged to the powers of the constituent entities of the Russian Federation.

Part 2 of this article has been declared invalid, and therefore, in accordance with the current legislation, certain powers in matters of protecting the health of citizens cannot be transferred by the Russian Federation to the constituent entities of the Russian Federation and the constituent entities of the Russian Federation cannot transfer their powers to the Russian Federation. This corresponds to the concept of the law on a strict division of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local governments.

In the article defining the powers of public authorities of the constituent entities of the Russian Federation (Article 6), a number of powers of public authorities of the constituent entities of the Russian Federation are set out in a new edition, which led to a change in the content of the powers. The powers of government bodies of the constituent entities of the Russian Federation include the development and implementation of programs for the development of healthcare, disease prevention, provision of medical care, medical education of the population and other issues in the field of protecting the health of citizens; establishing the structure of governing bodies of the state healthcare system of the constituent entities of the Russian Federation, the procedure for their organization and activities; development of healthcare institutions in the constituent entities of the Russian Federation; their logistics; control over compliance with standards of medical care in the manner established by the legislation of the Russian Federation and the legislation of the constituent entities of the Russian Federation; formation of budget expenditures of the constituent entities of the Russian Federation for healthcare in terms of the provision of specialized medical care in dermatovenerological, anti-tuberculosis, drug treatment, oncology 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 drugs, medical products, immunobiological preparations and disinfectants, as well as donated blood and its components within the framework of the Program of State Guarantees for the provision of free medical care and compulsory medical care to citizens of the Russian Federation insurance of the non-working population, provision of specialized (sanitary and aviation) emergency 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 health insurance; establishing the procedure 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, establishing the procedure and volume of social support measures provided to certain groups of the population (in the old terminology - benefits) 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, regions will have to finance all their obligations, including preferential payments. Having strictly delineated powers in matters of social support with the subjects of the Federation, the federal center assigned responsibility for possible social problems to the regions.

The powers to issue permits for the use of new methods of prevention, diagnosis and treatment, new medical technologies, and the powers to license 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 state authorities of the constituent entities of the Russian Federation in matters of health protection to state authorities of the Russian Federation was declared invalid.

In accordance with the amendments, the jurisdiction of local government bodies (Article 8) includes monitoring compliance with legislation in the field of protecting the health of citizens; protection of human and civil rights and freedoms in the field of health care; 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 healthcare system; organization of primary health care in outpatient clinics, inpatient clinics and hospitals, including the provision of these medical organizations with medicines and other products, medical products, immunobiological preparations and disinfectants, as well as donated 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 sanitary aviation), ensuring its availability, monitoring compliance with standards of medical care, providing citizens with medicines and medical products in the territory under their jurisdiction; environmental protection and ensuring environmental safety.

It should be noted that neither the powers of state authorities of the constituent entities of the Russian Federation, nor the powers of local governments included the organization and financing of specialized medical care in municipal healthcare organizations.

A number of changes concern 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 authorities in the field of health care, executive authorities of 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 subordinated to the management bodies of the state health care system, treatment and preventive and scientific research institutions, educational institutions, pharmaceutical enterprises and organizations, pharmacy institutions, sanitary institutions, territorial bodies created in the prescribed manner for implementation of sanitary and epidemiological supervision, forensic medical examination institutions, logistics services, enterprises for the production of medicines and medical equipment and other enterprises, institutions and organizations.

The state health care system includes medical organizations, including treatment and preventive institutions, pharmaceutical enterprises and organizations, pharmacy institutions created by federal executive authorities in the field of health care, other federal executive authorities and executive authorities of constituent entities of the Russian Federation.

Art. 13. Municipal health care system - set out in the following wording.

The municipal healthcare system may include municipal healthcare authorities, as well as municipally 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 healthcare system is an expenditure obligation of the municipality.

The provision of medical care in organizations of the municipal health care system can be financed from compulsory health insurance and other sources in accordance with the legislation of the Russian Federation.

Art. 14. Private health care system - set out in the following wording.

The private health care system includes medical and preventive care and pharmacy institutions, the property of which is privately owned, as well as persons engaged in private medical practice and private pharmaceutical activities.

The private healthcare system includes medical and other organizations created and financed by legal entities and individuals.

A number of changes concern the rights of citizens in the field of health care.

Part of Art. was declared invalid. 20, according to which citizens had the right, in case of illness, to 3 days of unpaid leave during the year without presenting a medical document. This part is in conflict with the Labor Code of the Russian Federation.

Part 5 Art. 23. The rights of pregnant women and mothers are set out in the following wording.

“The procedure for providing nutritious food to pregnant women, nursing mothers, as well as children under 3 years of age, including through special food outlets and shops based on the conclusion of doctors, is established by the legislation of the constituent entities of the Russian Federation.” Thus, the provision on state guarantees of providing pregnant women, nursing mothers and children under 3 years of age with adequate nutrition has been excluded.

In Art. 24. 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 healthcare, and on the 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 consultation when determining professional suitability has been transferred to the constituent entities 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 disabilities of physical or mental development at the request of parents or persons replacing them, they may be kept in social protection institutions in the manner and under the 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, federal government bodies no longer have the authority to implement the rights of minors. All responsibility for the implementation of the rights of minors falls on the subject of the Russian Federation and depends on the availability of money in the budget of this subject of the Russian Federation.

The right to receive medical care in 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 providing medical care to this category of citizens.

Art. declared invalid. 26. Rights of elderly citizens; Art. 27. Rights of persons with disabilities; Art. 28. Rights of citizens in emergency situations and in environmentally unfavorable areas.

It is assumed that the rights of these population groups should be enshrined in special laws.

Section VIII has been amended. Guarantees for the provision of medical and social assistance to citizens.

Art. 38. Primary health care - set out in the following wording.

Primary health care is the basic, accessible and free type of medical care for every citizen and includes 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 their place of residence.

Primary health care is provided by institutions of the municipal health care system. Institutions of public and private health care systems may also participate in the provision of primary health care on the basis of agreements with insurance medical organizations.

The scope and procedure for the provision of primary health care is established by legislation in the field of protecting the health of citizens.

Financial support for activities to provide primary health care in outpatient clinics, inpatient clinics and hospitals, 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. Emergency medical care - set out in the following wording.

Emergency medical care is provided to citizens in conditions requiring urgent medical intervention (in case of accidents, injuries, poisoning and other conditions and diseases), provided immediately by medical institutions, regardless of territorial, departmental subordination and forms of ownership, by medical workers, as well as by persons obligated to provide it in the form of first aid by law or by special rule.

Emergency medical care is provided by institutions and departments of emergency medical care of the state or municipal health care system in the manner established by the federal executive body that carries out legal regulation in the field of health care. Emergency medical care is provided to citizens of the Russian Federation and other persons located on its territory free of charge.

Financial support for measures to provide 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 for measures to provide emergency medical care (with the exception of sanitary 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 bill of the Government of the Russian Federation, and with great difficulty it was possible to defend and preserve it.

Art. 40. Specialized medical care - set out in the following wording.

Specialized medical care is provided to citizens for diseases that require special diagnostic methods, treatment and the use of complex medical technologies.

Specialized medical care is provided by medical specialists in medical institutions that have received a license for this type of activity.

The types and standards of specialized medical care provided in health care institutions are established by the federal executive body that carries out legal regulation in the field of health care.

Financial support for measures to provide specialized medical care in dermatovenerological, anti-tuberculosis, drug treatment, oncology clinics and other specialized medical organizations (with the exception of 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 for measures to provide 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 healthcare 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 healthcare organizations (both outpatient clinics and inpatient clinics). Accordingly, the law does not contain a clause on financial support for measures to provide specialized medical care in municipal healthcare organizations.

Thus, primary health care will be provided only at the municipal level, and specialized care, including in municipal health care organizations, if there is one (with the exception of federal specialized medical organizations, the list of which is approved by the Government of the Russian Federation), in accordance with according to these Fundamentals, must be organized and financed by a subject of the Federation. This corresponds to the principle of separation of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local governments, but will create difficulties in practical healthcare when organizing and financing specialized medical care in municipal healthcare 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 state authorities of the constituent entities of the Russian Federation. Financial support for measures to provide medical and social assistance to these citizens is an expenditure obligation of the constituent entities of the Russian Federation.

The question inevitably arises: are there socially significant diseases in a particular region, and the state as a whole is not responsible for diseases that arise for social reasons? In addition, given the different financial capabilities of the constituent entities of the Federation, a patient with the same disease will have different opportunities to receive medical and social care in different territories.

Art. 42 is devoted to medical and social assistance to citizens suffering from diseases that pose a danger to others. In accordance with the new Fundamentals, the word “free” has been removed from the provision of medical and social assistance to these citizens. In accordance with the amendments, medical and social assistance to citizens suffering from diseases that pose a danger to others is provided only in institutions of the state healthcare system intended for this purpose (municipal healthcare 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. Social support measures in the provision of medical and social assistance and drug provision to these citizens are established not at the federal level, but by state authorities of the constituent entities of the Russian Federation. Financial support for measures to provide 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 territorial programs developed in accordance with the federal program do not take into account the types and volumes of medical care in epidemic conditions and, accordingly, are not funded for this case.

In connection with the changed social policy, Art. 50. Medical and social examination. This article is presented in the following edition.

Medical and social examination is carried out by federal institutions of medical and social examination in the manner established by the legislation of the Russian Federation.

A citizen or his legal representative has the right to invite, upon his application, any specialist with his consent to participate in a 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 permission to engage in private medical practice in the territory under its jurisdiction was declared invalid. Private medical practice is carried out on the basis of a license; establishing the procedure for licensing medical activities falls within the powers 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 healthcare, unless otherwise provided by federal law.

Thus, legislative control over the activities of the private healthcare system by the federal executive body has been strengthened. The question arises of how the Ministry of Health and Social Development of the Russian Federation will be able to organizationally implement this control in all regions of the vast country.

Art. 59. General practitioner (family doctor) - set out in the following wording.

General practitioner (family doctor) is a doctor who has undergone special multidisciplinary training to provide 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 and 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 acquisition of residential premises, installation of a telephone, provision of places for their children in pre-school and sanatorium-resort institutions, acquisition on preferential terms of vehicles used to perform professional duties during the traveling nature of work, and other benefits provided for by law are excluded. The right of doctors, pharmacists, employees with secondary medical and pharmaceutical education of the state and municipal health care systems, working and living in rural areas and urban settlements, as well as members of their families living with them, to free provision of apartments with heating and lighting in accordance with the current legislation.

These rights, despite their legislative enshrinement, were not implemented.

In this case, the tendency to build a rule of law state based on the rule of law is clearly visible. The laws adopted during the period of socialism and post-socialism did not skimp on rights, but some rights did not have mechanisms for implementation. This seemed not so important, since there was no obligation to comply with the laws. State administrative mechanisms both protected the citizen and suppressed him. With the construction of the rule of law, the role of law in society has increased, citizens have learned to defend their rights enshrined in the law in court. 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 of implementing the law.

This article has been supplemented with the following parts.

Social support measures 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 state authorities of the constituent entities of the Russian Federation.

Social support measures for medical and pharmaceutical workers of municipal healthcare organizations are established by local governments.

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 governments, however, the division of medical workers in matters of social support at levels - federal, regional and municipal - will lead to inequality of rights of citizens in the territory of the state.

Art. 64. Compulsory insurance of medical, pharmaceutical and other employees of the state and municipal healthcare systems, whose work is associated with a threat to their life and health - is set out in the following wording.

For medical, pharmaceutical and other employees of the state and municipal healthcare 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 workers, 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 involves 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 employees of healthcare organizations under the jurisdiction of a constituent entity of the Russian Federation, whose work involves 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 healthcare organizations, whose work involves a threat to their life and health, are established by local governments.

In the event of the death of employees of the state and municipal healthcare systems while performing their job duties or professional duties while providing medical care or conducting scientific research, the families of the deceased are paid a one-time cash benefit.

The amount of a one-time cash benefit in the event of the death of employees of federal specialized healthcare organizations is established by the Government of the Russian Federation.

The amount of a one-time cash benefit in the event of the death of employees of healthcare 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 healthcare organizations is established by local government bodies.

In accordance with Art. 15 of the new law amends the Law of the Russian Federation dated July 2, 1992 No. 3185-1 “On psychiatric care and guarantees of the rights of citizens 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 mental health care.

Resolution of issues of social support and social services for persons suffering from mental disorders and in difficult life situations is carried out by state authorities of the constituent entities of the Russian Federation.

Art. 17. Financing of mental health care - set out in the following wording.

Financial support for 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 who are in difficult life situations, is an expense obligation of the subjects Russian Federation.

With a lack of financial resources, the subjects of the Federation are unlikely to be interested in developing psychiatric services; this category of patients in a number of regions may find themselves without specialized medical care.

Art. 22. Guarantees for psychiatrists, other specialists, medical and other personnel involved in the provision of psychiatric care are set out in the following wording.

1) Psychiatrists, other specialists, medical and other personnel involved in the provision of psychiatric care have the right to reduced working hours, additional leave for work in especially hazardous 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 in the performance of official duties in the manner established by the legislation of the Russian Federation; compulsory social insurance against industrial accidents and occupational diseases in the manner established by the legislation of the Russian Federation.

The question arises: how does working with patients with mental illnesses in federal healthcare institutions differ from working with patients with mental illnesses in medical institutions of the constituent entities of the Russian Federation, if the personnel working with them have different allowances?

In Art. 45 the procedure for monitoring activities in the provision of mental health care has been changed. Control over the activities of federal psychiatric and psychoneurological institutions is carried out by authorized federal executive authorities, control over the activities of psychiatric and psychoneurological institutions under the jurisdiction of a constituent entity of the Russian Federation is carried out by an authorized federal executive authority and executive authorities of constituent entities of the Russian Federation.

Control over the activities of federal psychiatric and psychoneurological 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 06/09/93 No. 5142-1 “On the donation of blood and its components”.

In Art. 1 The upper age limit has been removed. Every capable citizen over the age of 18 (in the old version - up to 60 years) who has undergone a medical examination can be a donor of blood and its components.

The article on federal programs for the development of blood donation has been excluded. There will no longer be such programs that are legally obligatory for the state.

Art. 4. Providing activities for the development, organization and promotion of blood donation and its components - set out in the following wording.

Financial support for activities for the development, organization and promotion of blood donation and its components, carried out in order to provide specialized medical care provided by federal healthcare organizations, is an expenditure obligation of the Russian Federation.

Financial support for activities for the development, organization and promotion of blood donation and its components, carried out in order to provide specialized medical care (except for that provided by federal health care organizations), specialized (sanitary and aviation) emergency medical care, is an expenditure obligation of the constituent entities of the Russian Federation.

Financial support for activities for the development, organization and promotion of blood donation and its components, carried out in order to ensure the provision of primary health care, medical care for women during pregnancy, during and after childbirth and emergency medical care (with the exception of sanitary and aviation), is an expenditure obligation of municipalities.

The implementation of measures for the development, organization and promotion of blood donation and its components is carried out on the basis of creating a unified information base in the manner established by the Government of the Russian Federation.

Art. 11 defines social support measures for persons awarded the “Honorary Donor of Russia” badge. Financial support for expenses related to the implementation of the rights of honorary donors remains an expenditure obligation of the Russian Federation, i.e., 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 amends Federal Law No. 38-FZ of March 30, 1995 “On preventing the spread of the disease caused by the human immunodeficiency virus (HIV infection) in the Russian Federation.”

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 medications for the treatment of HIV infection on an outpatient basis in federal specialized medical institutions in the manner established by the Government of the Russian Federation Federation, and in healthcare institutions under the jurisdiction of a constituent entity of the Russian Federation, in the manner established by the state authorities of the constituent entities of the Russian Federation.

Art. 6. Financial support for activities to prevent the spread of HIV infection - set out in the following wording.

Financial support for measures to prevent the spread of HIV infection carried out by federal specialized medical institutions and other organizations of federal subordination is included in the expenditure obligations of the Russian Federation.

Financial support for 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 is included in the expenditure obligations of the constituent entities of the Russian Federation.

Art. 21. State one-time benefits are declared invalid. 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 one-time benefits in the event of HIV infection while on duty has been eliminated.

Art. 22. Guarantees in the field of labor - set out in the following wording.

1. Employees of enterprises, institutions and organizations of the state health care system that diagnose and treat HIV-infected people, as well as persons whose work involves materials containing the human immunodeficiency virus, have the right to reduced working hours, additional leave for work in particularly 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 and difficult working conditions for employees of federal healthcare institutions is determined by the Government of the Russian Federation.

The procedure for providing these guarantees and establishing the amount of bonuses to official salaries for work in especially hazardous 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 healthcare system that diagnose and treat HIV-infected people, as well as persons whose work involves materials containing the human immunodeficiency virus, are subject to compulsory insurance in the event of harm to their health or death in the line of duty in the manner established by the legislation of the Russian Federation; compulsory social insurance against industrial accidents and occupational diseases in the manner established 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 and working with HIV-infected blood in medical institutions of the constituent entities of the Russian Federation, if the staff have different allowances?

In accordance with Art. 135 of the new law amended the Federal Law of June 18, 2001 No. 77-FZ “On preventing 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 to ensure economic, social and legal conditions for preventing 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 in the following wording.

Subjects of the Russian Federation organize the prevention of the spread of tuberculosis, including anti-tuberculosis care for tuberculosis patients in anti-tuberculosis dispensaries, other specialized medical anti-tuberculosis organizations and other health care 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 conditions of people’s lives,

The state’s refusal to influence the social conditions of people’s lives, the redistribution of responsibility for social support measures and financial support for measures to provide medical and social assistance to citizens suffering from socially significant diseases to government 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 their budgets to treat such a pathology. An individual subject of the Federation, no matter how good everything is in this subject (even an oil-producing, rich region that is a donor of the federal budget, capable of providing social support to the residents of its region), cannot influence the situation as a whole in the country. No one can restrict a citizen’s constitutional right 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 better funded social support system. The influx of socially disadvantaged citizens into the regions, namely they most often have socially significant diseases, is unlikely to have a positive impact on the development of these regions.

In addition, reducing the state's responsibility for social processes occurring in this state is a blow to the authority of the state as a whole and undermines faith in the social orientation of state policy.

The provision of anti-tuberculosis care to citizens in accordance with the adopted changes is carried out not on the basis of the principle of free care (in the old version), but in the volumes provided for by the Program of State Guarantees for the provision of free medical care to citizens of the Russian Federation. The program of state guarantees for the provision of free medical care to citizens of the Russian Federation is implemented in the territories through territorial programs, which are financed differently in different territories. Thus, if there is insufficient funding for 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 tuberculosis patients. This will lead to a worsening of the already unfavorable epidemic situation regarding tuberculosis in certain regions and throughout the country as a whole.

Excluding from the rights of persons under observation for tuberculosis and tuberculosis patients the right to free travel on public transport in urban and suburban traffic when calling or referring for consultations to medical anti-tuberculosis organizations is unlikely to contribute to improving the epidemic situation, especially in rural areas .

The rights of persons under observation for tuberculosis and tuberculosis patients to be provided with free medicines for the treatment of tuberculosis are set out in the following wording.

Persons under dispensary observation in connection with tuberculosis and tuberculosis patients are provided with free medications for the treatment of tuberculosis on an outpatient basis in federal specialized medical institutions in the manner established by the Government of the Russian Federation, and in health care institutions administered by 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 contagious forms of tuberculosis living in apartments in which, based on the living space occupied and the composition of the family, it is impossible to allocate a separate room to a patient with a contagious form of tuberculosis, communal apartments, dormitories, as well as families with a child sick with a contagious form of tuberculosis, are provided with queues of separate residential premises, 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 for medical, veterinary and other workers directly involved in the provision of anti-tuberculosis care is set out in the following wording.

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 particularly hazardous situations 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 and difficult working conditions for employees of federal healthcare institutions is determined by the Government of the Russian Federation.

The procedure for providing these guarantees and establishing the amount of bonuses to official salaries for work in especially hazardous 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 sick with tuberculosis, are subject to compulsory insurance in the event of harm to their health or death in the line of duty in the manner established by the legislation of the Russian Federation; compulsory social insurance against industrial accidents and occupational diseases in the manner established by the legislation of the Russian Federation.

The same question: how does working with tuberculosis in federal healthcare institutions differ from working with tuberculosis in medical institutions of the constituent entities of the Russian Federation?

These are the main changes made to Russian healthcare legislation in connection with the adoption of the new law. Also, major changes have been made to federal laws in the field of protecting the health of citizens, directly related to health care legislation: “On the immunoprophylaxis of infectious diseases” (dated September 17, 1998 No. 157-FZ); “On the sanitary and epidemiological welfare of the population” (dated March 30, 1999 No. 52-FZ); “On Medicines” (No. 86-FZ dated June 22, 1998); “On the quality and safety of food products” (dated 01/02/2000 No. 29-FZ); “On specially protected natural areas” (dated March 14, 1995 No. 33-FZ).

In general, it should be noted that although the division of powers between federal government bodies, government bodies of the constituent entities of the Russian Federation and local governments was certainly intended to change the system of interbudgetary financial relations within the Federation, including health care financing, the law did not simplify, but complicated the organization and inter-budgetary relations regarding the financial provision of medical care. For example, difficulties will arise in realizing the right of citizens to medical care in the provision of emergency, primary health care, and specialized medical care due to insufficient financial resources 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 of providing citizens with free medical care for the main types and volumes of medical care provided for in the federal program.

2.2 Current issues of legal regulation of economic aspects of the activities of healthcare 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 simple consumers of budget resources into independent economic entities, the introduction of compulsory and voluntary health insurance, the development of entrepreneurial activity and other innovations required significant reform of business methods. Meanwhile, there are serious problems in the legal regulation of the economic aspects of the activities of medical institutions, which can be grouped as follows: lack of legal regulation of certain aspects of the activities of medical institutions; insufficient legal framework in certain areas of activity; inconsistency of legal regulation; the presence of legal norms that have controversial interpretation; inconsistency of legal regulation with the objectives of healthcare development or the interests of the state; insufficient legal literacy of heads of medical institutions; problems of implementing the legal rights of medical institutions in economic matters.

Let's look at these groups of problems in more detail.

Lack of legal regulation of certain aspects of the activities of medical institutions. The dynamism of processes occurring in society and, in particular, in healthcare, leads to the fact that legal regulation does not keep up with the pace of reforms. Therefore, at present there is no legal regulation of a number of economic issues in the activities of healthcare institutions. This applies, for example, to some aspects of the activities of medical institutions related to the use of state (municipal) property when budgetary medical institutions carry out business activities. In particular, this applies to the use of buildings (premises). Budgetary medical institutions, as part of their core activities, use buildings and structures free of charge. Accordingly, there is no methodological or regulatory basis for including the cost of these resources (depreciation) in prices for paid services. However, prices for paid services are based on the market level, formed primarily by commercial non-state medical institutions and including all types of costs, including depreciation of buildings. In this situation, budgetary institutions, providing paid services at market prices, receive excess profits, the real basis of which is the cost of buildings not reimbursed to the budget (in the form of depreciation or rent).

Currently, there is no necessary legal regulation of a number of issues related to guarantees of free medical care. Everyone is well aware that the types and volumes of medical care assumed by state guarantee programs to provide citizens with free medical care exceed the financial capabilities of the budget and compulsory health insurance (CHI). 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 public funds. The deficit of funds under this program is 30-40 percent of the need, and it is covered.. . forced expenses of patients to pay for medications and medical services." Meanwhile, medical institutions cannot fail to implement the state guarantee program, and there is no officially established mechanism for compensating for the lack of financial support for the territorial state guarantee program at the expense of the budget or funds of the population. There is also no regulatory regulation of the situation where the volume of free care provided for by the program is exceeded within a specific medical institution or throughout the entire territory. It is absolutely 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 a violation of several laws, including the Criminal Code. But can an 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 dated September 11, 1998 No. 1096 “On approval of the program of state guarantees for providing citizens of the Russian Federation with free medical care,” nor other regulations devoted to this problem provide 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 so-called co-payments. There is currently no legal regulation of this form of compensation for the lack of budget funding or compulsory medical insurance funds.

Insufficient legal framework in certain areas of activity. Ten years of experience of medical institutions in the compulsory medical insurance system has revealed the need to improve legislation in this area. Let's give an example. The current legislation does not provide a clear definition of exactly what level of budget funds should be used to provide compulsory medical insurance (who exactly should be the insured) of the non-working population. In Art. 2 of the Law “On Medical Insurance of Citizens in the Russian Federation” states that the insurers of the non-working population include both government bodies of the constituent entities of the Federation and local administrations. Therefore, in different regions this problem is solved differently: 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 resolved by the law “On Compulsory Health Insurance” that is currently being developed.

The legal regulation of relations in the sphere of private medical activities cannot be considered sufficient. Medical activity is a special type of activity with a high risk to life and health. In the private healthcare sector, unlike the state and municipal ones, there are no bodies and management structures that organize this activity and exercise leadership and control. In order to fill these gaps, the Committee on Health and Sports of the State Duma has prepared a draft Federal Law “On the Regulation of Private Medical Activities”.

The increase in the volume of paid services provided by state and municipal medical institutions also revealed a number of problems associated with the procedure for their provision. In some cases, there is an uncontrolled development of the entrepreneurial activity of medical institutions, which is detrimental to the interests of the state and the population, in other cases, higher authorities put obstacles in the way of reasonable areas for the provision of paid services. This is primarily due to the poorly developed regulatory framework for the provision of paid services in healthcare. At the same time, there is a fairly clear legal basis for the entrepreneurial activities 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 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 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 03/29/96 No. 109 “On the rules for the provision of paid medical services to the population”), only duplicated the Decree of the Government of the Russian Federation dated 01/13/96 No. 27 “On approval of the rules for the provision of paid medical services medical institutions for the population,” without introducing anything new. It is quite obvious that these rules do not cover the entire list of issues that arise when providing paid services. The few other orders of the Ministry of Health of the Russian Federation that address the provision of paid services (dated March 20, 1992 No. 93 “Approximate list of medical services provided at the expense of state, public organizations, institutions, enterprises and other economic entities with any form of ownership” do not fill all the gaps. as well as personal funds of citizens"; dated 06.08.96 No. 312 "On the organization of work of dental institutions in new economic conditions" etc.).

1970 1974-1975 1978-1979 1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 2.63 2.23 1.97 1.99 1.90 1.89 1.91 1.89 1.73 1, 55 1.39 1.39 1.35 1.28 1.17 Table 2 Comparative fertility levels in Russia and some European countries Number of births and deaths in total per woman 1985 1990 1993 1996 1997 Russia Great Britain...

Development of legal documents and taking measures for their implementation. Among the environmental program documents currently being implemented, special mention should be made of the federal target program “Ecology and Natural Resources of Russia (2002-2010)”, approved by Decree of the Government of the Russian Federation No. 860. This federal target program is of great importance for the development of individual regions, since its goals and objectives...