ORGANIZATION OF DIFFERENT TYPES OF TREATMENT-PROPHYLACTIC AID OF POPULATION. AMBULATORY-POLICLINIC HELP
In the last few years the economy of health service tested the native changes. For specialists which are attended to the problems of social medicine, the economic knowledge became extremely necessary now. Inputs of market relations in
The reform of economy and social sphere in our country conditions the definite changes in the system of health service. The conception of its development in the conditions of market economy expressly orients society on perception of medicine not only as a moral, legal, but above all things as socio-economic category based on the adequate economic providing according to volume and quality of actually executed medical services.
In perspective civilized market relations in the health service must become a real economic subject in the general infrastructure of the
It is necessary to consider the economic aspect of health service like the element of public production.Bisedes, in society the conditions for the origin and development in industry of market relationsare created.
About objective nature of necessity of their development in the home system of health service testify:
• awareness by the population of economic conditionality of their health;
• commercialization of health service;
• increase volume of requiring payment medical services;
• development of marketing operations;
• introduction of various forms of enterprise and others like that. Perspective of introduction at the state level the system of medical insurance creates real basic of forming various competition enviroment in to the health service.
For the successful reform’s advancement the extremly importance is attached to possession of the main economy bases of health service of practical producers of medical services – medical specialists of different types and levels (doctors, medical hurses and etc.), students of higher and middle medical educational establishments.
The economic environment of medical workers changes and firstly it is – practical doctor who can be:
• wageworker in the state establishment or medical enterprise;
• co-operator, tenant, shareholder, specialist, that attends to the individual private medical practice;
• to connect that and other forms of economic activity.
2. Peculiarity of socialistic and market model of health service.
The speech about necessit to provide the economic effectivity of the system of health service in the soviet terms was never held.According to marxism-leninism study the medicare did not create the cost, it was not the component part of gross national product (GNP), and that is why it was belonged to unproductive sphere. Here it is necessary to emphasize, that in the conditions of market economy which we strive to build,the medical service is like wares, it is the component part of GNP, its production and realization is submitted to economic laws of market. So the money on the health service in the soviet terms were assigned not accordingly to financy ability, or more exactly by necessity, but from some ideological reasons, were the manifestation of the care of party and government about people. If to cast out the grandiloquent argumentation,the reality was so, that this money(if taking no into consideration the absolute growth), in the relative calculation (concerning GNP) incessantly diminished and never made 6,5% of GMP,- did not attain of index which the World Health organization considers the border, below from which a health service is nonviable. To compare, all so-called civilized countries on the health service expenses are laid in range: 6,5 (
However, the essence of uneffectivity of the Ukrainian health service which even at present too inviolably abides by soviet bases of organization, consists in the full neglect of the economic laws concerning production of medical service as wares.
The economic science divides the charges of production to constant and variables. To constant ones in medicine it is necessary to concern apartments, their amortization, insurance payments. To variables – ones labour force, equipment, medicines, communication facilities, transport, bank’s services and others like that. The variable charges are determinative. The main principles of determination and calculation of variable charges are based on conception of maximum productivity of variable factors of production and laws of its gradual reduction, because of it the vergen expenses gradually increase. The conception essence is that production of medical services has to ensure its highest cost at the set charges, because the cost determines quality and commodity effectivity.
Quality and effectivity of medical service – is its cost. The higher cost the higher, quality and effectivity of service and vice versa.
In the soviet terms this reflection was not in use, but increase of number of medical staff, hospital beds which were planned indexes of medicare development. Exactly thanks to indexes the soviet medicine took the first place in the world, and exactly with their help its leading nature was substantiated.
The swift increase of quantity of personnels and beds was resulted in two economic consequences. Firstly, the part of charges on wages which was given to medical workers from the general budget constantly grew. Its attained 60% of this charges. That is only 40% was expended on other things-equipment, medicines, transport,communication and others like that.It became naturally,that the providing of medical establishments with newest medical equipment and medicines became to lag behind incessantly. Secondly,awerage wages of medical workers were considerably lower in comparison with other branches of national economy, and this break also grew constantly. Remember: the bus driver got 280-300 roubles in monthly, and ordinary doctor – 100-120.
Such system of medicare could make only cheap and low in quality and efficiency medical services. The low cost of ordinary medical service lies in basis of lag of the former soviet and nowaday Ukrainian health service from the world’s standards. That is why the ordinary Ukrainian sick an operation on heart concerning the aortal shunting is not accessible (the necessity in such operations in Ukraine annually makes about 50 thousands, about 200 are done), transfer of organs and systems, medical treatment of laucosis, help at the chronic kidney insufficiency and others like that. At the huge number of doctors, including doctors with the scientific degrees, our sick man can get the help in these and other hard cases only abroad.
A strategic course was taken on the total specialization. The specialization gave a new growth quantity of personnels and beds. The therapeutist, paediatrician, accoucheur-gynaecologist came into place of doctor of general practice, then into place of therapeutist – cardiologist , gastroenterologist, nephrologist, haematologist, pulmonologue came etc. It was considered, that the narrower the sphere of the personal interests of doctor,will be the doctores will be deeper oriented in it. In spite of growth of number of graduating students from the medical educational establishments, they could not run after the specialization.So in the eighty years 70 thousands of doctors were infused additionally into ukrainian medicare system.So the providing with them was increased on a third,but the “linsuffeiency” of doctors grew. If in 1980 every fifth post of doctor in the medical establishments was vacant,but in 1992 – every fourth was.
The specialization has led not to the rise of quality and efficiency, but to the reverse result. The lag from the warlds standards deepened. Why? Because, the specialization resulted in huge growth of number of medical services, that were made by the system, and the cost of ordinary medical service in the conditions of the limited financing diminished incessantly.
What is to be done for the Ukrainian health service, which has got to impasse? It is necessary to divide the present system into three parts or subsystems: state, public, private. About subsystem which the state can maintain , the speech was held higher. It will give to citizens of
The competition between these parts (and without competition there is not a market)will arise up, and possibility of free choice of doctor will appear , that is the sacred right of all citizens of democratic world. A state must take under the hard control (civilized market differs from a wild,one that there is a hight regulative role of state in it) preparation of personnels and pricing medicare. It is not difficult to prognose, that in this conditions the considerable part of medical workers will not bear the competition and must search for other job. Exactly this considerable part together with not relatively less part of explorers to which it is easier to yell about shortage of facilities in the health service, than high-quality reconstruct it, is that brake, that was and while remains insuperable.
5. The conception of the health protection reform in
1. The main foundations of the organization of the medical aid in
The own historic way of development and the experience of the leading Western countries testify that the main volume of medical aid for people must be provided by the state. Io country of the world, except the
The leading role of the state is conditioned by two main reasons: firstly, the system of health care is one of the decisive factors with the help of which the state weakens the shortcomings of the market economy, precisely – inability to compete characteristic of the poor layers of the society, and also pensioners, the disabled, those who oftener than others fall ill and die. Secondly, unlike the dynamics of prices for the majority of goods, which has the tendency towards getting lower, the cost of medical services is permanently increasing. Only the state regulation is able to soften the negative results of this tendency. So, the system of health care in
At the same time, in order to deprive the state of the monopoly in the health care system, there public and private forms of ownership must be developed, they must be giveot only the equal rights with the state one, but also during the period of their foundation – certain privileges, otherwise they will not be able to develop and compete with the state system. Different forms of ownership are to be independent of each other. This point must be emphasized on, as there can be seen some attempts to unite under the roof of the state medical establishments different forms of ownership. This is nothing else but trying to preserve the system, which has gone bankrupt.
Of course, the efforts of the state, public and private medical institutions must be coordinated and directed towards accomplishment of the common aim – improvement of people’s health, but this coordination must be done at the state level and regulated by the corresponding legislation.
The system of health care in
The limit of the economical profitableness of the state establishments is reaching the highest effectiveness possible at the lowest expenses, the public and private establishments – getting the maximum of profit, which must be limited only by the state and regulated by the corresponding legislation.
In order to achieve the economical effectiveness in the state sector of health care, such main measures should be taken: organizational reconstruction of all the levels of medical aid; introduction of scientifically-grounded standards of the amount and cost of medical aid in every of the levels; free doctor’s selection; introduction of economical incentives of the medical personnel’s work.
The social effectiveness of medical help lies in its equality for various layers of the society. The same cost and quality of medical help must be provided for the poor and rich, also it must be kept in mind that unhealthy condition of the society is determined, first of all, by its poor part.
The prophylactic slant of the health care system must be preserved, but first of all it must be considerably corrected in the sphere of medical establishments’ activities.
The first direction of the prophylactic is the improvement of the social-economical conditions of work and everyday life. In the realization of the latter the sanitary anti-epidemic service, which must remain in the state ownership and must work in accordance with the valid legislation takes part.
The prophylactic direction of treatment activities or dispensaries also needs considerable correction. The demand of the population for medical aid is to become its basis. Prophylactic examinations must be done in the process of asking the citizens for medical aid and with their consent only. Doctors of general practice and family doctors must provide their main amount and dynamic observation. The active forms of dispensary activities are used only in order to prevent and find infectious, venereal diseases, AIDS and tuberculosis, and also towards the certain professional groups.
The reform of the health care system needs permanent scientific provision.
A number of urgent tasks of methodological and organizational nature have been set to the Ukrainian medical science. These are the following: forming its conception as the original branch of the European and world science, becoming on the equal footing the part of the world scientific partnership, formulating the scientific priorities, forming the structure and volume of scientific research, the development of the Academy of medical sciences with founding powerful scientific institutions, etc.
Social medicine is the theoretical basis of the organization of medical aid. The need in the development of social-medical research in the sphere of organization, management and economics of medical aid is particularly pressing. That is why the scientific-research institutions of this type must be developed.
Consequently, the reform of the health care system in
– The state nature with the equal existence of public and private forms of ownership;
– Economical and social effectiveness;
– Prohpylactic direction;
– Scientific provision;
– Adoption suitable for
2. The organizational reconstruction of the state health care system.
The state is responsible for providing all its citizens with the guaranteed amount of medical aid in spite of the parallel existence of the public and private medicine. It is determined by:
-The existing level of illnesses of the population and the need of realization of appropriate diagnostic, treating, rehabilitating and prophylactic measures;
-The amount of the gross national product and the share given to the medical help;
-Salaries of the medical staff and its share in concerning all expenditures on the medical aid.
These very criteria must be used for estimation of the necessary material-personnel recourses in the state health care system.
The Ukrainian social-medical science has gathered the sufficient data necessary for the evaluation of the level of diseases the population of
In the Soviet times no more than 6.5% of the gross national product was spent on the health care. The World Organization of Health Protection considers this level to be the lowest boundary-line, under which the system stops to be viable. This very index
The next important moment is the salary of the employees working in the system. It must be equal to the average wages earned in the industry.
3. The mechanism of the health care funding.
First of all the financial independence of the primary section must be provided. The family divisions must be funded directly from the local budget at the rate of one resident. The latest researches have shown that amony all means spent on the medical aid the primary level comprises about 16%.
Some (venereological, tubercular, psychiatric-neurological, oncological) medical establishments considered to the second and third levels are to remain directly financed in accordance with the need and norms of the service the patients being provided with.
As for the funding other medical establishments of the second and third levels, a few variants can be suggested. The first variant is the most optimal one, it includes the additional economical lever of the sphere’s improvement: the second and third levels earn money in the primary section being rewarded for providing with the service those patients, which are directed from the primary level. The so-called “new economic mechanism” has been based on such kind of funding. This variant is still premature, because the primary section is too weak. The second variant: the payment for the services of the second and third levels is done in accordance with the need and scientifically grounded service norms.
There are three variants of the mechanism of the payment for the medical service: via medical banks, non-commercial insurance companies or with preserving the existing system. The insurance companies variant is better but also much more expensive. That is why transferring the role of the fund-keepers to the insurance companies is inexpedient in the state health care system, and it is quite evident that the existing mechanism of budget payments should be preserved.
4. The reorganization of the management of the health care system.
There exist three levels of management in the state system: basic (village district, town), regional (region) and state. Nowadays all of them do not meet the requirements of the time, as they are not able to ensure the transfer of the health care to the market foundations.
The leading specialists – therapeutists, surgeons, pediatricians, gynecologists, epidemiologists, and etc, play the main role in the structure of management. They are the staff specialists. There is also a great number of not on the staff ones, such as the chief doctors of the specialized dispensaries, the heads of the departments of the oblast’ hospitals, the specialists of the scientific-research institutions.
Such system was finally formed in the first post-war years. The highly qualified leading specialists were appointed at the head of the army of widely available but trained in haste workers. Their task was to direct “the army’s” activities in a certain way, which is the main distinctive feature of the poorly developed health care system.
The change of the management functions must take place. On the basic level there must be ensured, first of all, medical and economical effectiveness, on the regional and state levels – social and economical ones.
The main function of the basic level is operational management, of the regional and state levels – strategic one.
On the basic level there must be formed the informational system, which gives “the dispatchers” not only the data about the state of the population health and activities of the medical establishments, but also the cost of the medical aid with proceeding from a certain doctor and a certain disease.
The social function of the health care system consists in arranging measures oriented towards the health of the social layers of the society.
A person’s belonging to this or that stratum considerably stipulates for the level and style of life. Well-being of a person including his health, first of all, depends upon a degree to which the society defends his stratum interests.
The health care still does not execute this extraordinarily important function. It even has no information concerning the social differences in the state of health of separate layers of the society.
The first step to be taken is creating the informational system, which would give the data concerning the population health not in general but of every social stratum. This work must be led and directed by scientific-informational centers consisting of the regional health protection departments at the state level. On the basis of the information there must be developed and realized the goal-oriented complex programs, aimed at health improvement of those social layers of the population where it is the worst one.
Reorientation of the functions of the regional and state levels of management towards providing the social and economical effectiveness of the system is impossible without radical structural reconstruction of these bodies. The leading specialists are not necessary here. The basis of these bodies must consist of workers of social medicine and medical statistics, managers, economists, lawyers, specialists in the sphere of information.
The management reform needs the existence of a leader-administrator of a qualitatively new type, who would be knowledgeable in the fundamentals of the management science, its economical methods and would be able to work in the market-economy conditions. This position must be taken by a health protection manager (medical education is not obligatory) who has profound knowledge of management, economy and law, and who can execute his administrative functions in the conditions of unexpected situations and competition.
Elaborating of the model of such specialist requires adoption of the highly developed countries’ experience. The place of his training must become the school of health protection managers, which would exist within the limits of the health protection system and fulfill the social order for the preparation of a necessary specialist, its activities will further the gradual change of the existing health protection organizers into administrators, who would approach the world standards in the level of their preparation.
5. Training and retraining of the medical staff.
The already-started reform of the higher medical education must be one of the most important parts of the general reform, with future multi-structure of the health care system being taken into account.
Also it is important that the higher medical education should be regarded as the united system, which consists of two sub-systems: the higher basic and postgraduate education. In connection with this their reforming as the indivisible whole must be realized with using the systematic complex approach.
Reforming the higher medical school in the direction of its improvement with the national and suitable for
Special attention must be paid to the legislative acknowledgement and organization of the training of family doctor who must become the central figure of the future medical aid.
Eliminating iew conditions one of the most significant shortcomings of the existing fundamental medical education – insufficient preparation of medical institutions’ graduates to the independent practical activities – requires the goal-oriented steps to be taken, precisely:
-Reconsidering curricula in the direction of radical reduction in them, first of all, those subjects, which are studied at school, and teaching them only in the volume that will be necessary for a future doctor in his practical activitys;
-Increasing the number of clinical subjects and helping students acquire practical skills during their studies;
-Radical changes of the method of teaching social medicine as science, which belongs to the sphere of activities of all future doctors;
-Change of the methods of internship studies in the direction of paying particular attentioot to the theory but to the maximum acquiring practical skills by future doctors-specialists;
-Introduction of learning a foreign language during the whole period of study at the educational institution.
There exists a need in reconsideration of approaches towards the post-graduate education on the side of organizers as well as doctors themselves. It must be provided with such legislative standardized state mechanisms, which would make the systematic improvement of knowledge not only the compulsory duty, but also the official one and what is of the main importance – the oweed of a specialist, without which it would be impossible, as the way is in the highly developed countries, his professional and official promotion.
The existent system of specialists’ certification also requires legislative and methodical improvement.
Reduction of admission to the medical educational institutions requires reconsidering and setting the network of basic as well as post-graduate education, creating the system of educational improvement for teachers of medical schools.
Nonsystematic and ungrounded organization of new higher medical educational institutions outside the health care system, which has been taking place in
6. Approaches to the organization of public and private medicine.
Out of the state health care system, which meets the modern requirements and recourses of
The succession of carrying out this task must be the following:
1.Realization of accrediting and licensing the medical institutions;
2.Selection of the best ones, which remain in the state ownership;
3.Privatization of the medical institutions, which have not received the state status via the open sharing;
4.Introduction of the mechanism of funding private and public establishments via voluntary medical insurance or medical banks.
The existing legislation about the privatization, free enterprise and tax policy contains insuperable impediments for the development of private and public forms of ownership in the health care system as alternative to the state one. That is why there must be drawn up a special law, which would take into account peculiarities of the medical provision of the Ukrainian citizens.
7. The reform’s legislative provision.
For the reform’s legislative provision there must be drawn up and presented in the Supreme Rada the drafts of such vital laws:
1.About the public and private ownership and practice in the health care system.
2.About the mechanism of funding of the state health care system.
3.About the voluntary medical insurance.
4.About the organization of the family medicine.
5.About the mechanism of the health protection management.
6.About hospitals’ activities.
7.About the patients’ rights.
Though, taking into the consideration the urgency of tasks concerning the health care system and duration of this process in the Supreme Rada, it is possible that the above-mentioned statements should be passed by means of edicts of the Ukrainian President.
