ORGANISATION OF THE PRIMARY MEDICAL-SANITARY CARE TO POPULATION.

ORGANISATION OF THE SECONDARY AND TERTIARY TREATMENT-AND-PROPHYLACTIC CARE TO POPULATION

 

In the last few years the economy of health service tested the native changes. For specialists who are attended to the problems of social medicine, the economic knowledge became extremely necessary now.  Inputs of market relations in Ukraine made search and development of various economic receptions and methods of management of health service, they made learning of medical, social and economic effectivity in giving the medicare to all layers of population an actual problem. The important role in decision of these tasks belongs to the economic theory. In case of its studing it is necessary to give up the idea, that the medical activity has unique features and that is why it doesn’t conform to the common economic laws, rules, methods and receptions of management of it. Indisputably, the economy of health service has its special specific and task, requires basic adaptation to the existent properties of economic theory. But many base categories of both economy of health service and economy of other industries, coincide by shape.

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 Ukraine economy.

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 (Great britain) – 15%(USA). It is needed to mean it, because somebody today’s economic difficulty in the Ukrainian health service links to independence, in the same time it was its constant chronic illness.

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 Ukraine so called assured volume of medicare. All, who will be dissatisfied with  this subsystem (medical workers, patients ones), will be able to realize themselves ,and other will be able to get help in the public and private medical establishments.

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.

 

3. Directions of reorganization of the Ukrainian medicare

 

        4. Planning and financing of health service establishments in the modern conditions

The economy of health service studies the action of market’s laws in the medicare system and influence of health service on labour force the basic factor of production.

An economic mechanism of modern market’s economy is the aggregate of public relations based on:

* the full relative production and economic apartness of producers by various goods and services;

* equality rights of all types of ownership;

* free pricing and competition;

* on the real co-operation of economic laws of market: cost law, competition, demand and supply, income law etc.

Health service like system of state, public and individual measures and facilities has not expressly outlined contours, sole management and others like that. On the one pole of this system are laws which are accepted by the state on service health of its citizens, on the other side is a conduct of citizens  themselves, on what their health depends  too. To explore this system from the position of market laws is hurdly; for the time being this problem is not only economic, but also political, social-psychological, and others like that.

Other business is the medicare system like component part of health service. It is separate industry of national economy, it has expressly outlined contours, external and inlying links, structural-functional descriptions, object and management subject. Therefore in the  determination of health service economy, like science, it is necessary to limit the study of action of market laws by the medicare system. As far as influence on health and recreation of labour force, as a basic factor of production, the speach must be held about the health service on the whole, as this influence is complex, here the all components of health service system operate in the indissoluble and permanent- tie.

There is no a sole determination of market notion. The researchers of the market system do not see the necessity in establishment of physical essence of market notion. It is determined, that the market notion essence foresees any nature of activity, where the processes of buying and sale are presented and where laws of market economy go into effect.

The notion of market economy engulfs the economic system in which the process of acceptance of decisions concerning production and allocation of resources is based on the basis of prices, created by the voluntary exchange between producers, buyers, workers and proprietors of other factors of production. At the acceptance of decisions in the conditions of economic relations of such nature is carried out decentralizedly. The market system foresees also equal in rights existence of different forms of property – private, public, state.

Basic laws of the market system are confirmed to a few major aspects:

– firstly, determination of basic principles of functioning separately taken markets and their intercommunication;

– secondly, establishment of dynamic development of basic elements of the market system – objects and volumes of production, facilities of production, subjects of consumption of production results;

– thirdly, determination of regulative role of the  state;

– the fourth   aspect   foresees   achievement   of the highest   level of national welfare.

The market system considers notions «commodity» and «favour» like equivalent. The commodity cost as the well as the cost of consumption of services in the equal measure are constituents of gross national product or gross national income.

Extrapolating laws of products and profits of appeal on the medicare system in the market conditions , it is possible to present them thus.

The medical establishments and medical staffs, that attend to the public or private practice, give medical services, they are paid for by the intermediary organizations as insurance firms ( to which the  state,  enterprises or citizens pass this facilities by the medical insurance) or immediately by state and citizens. The state gets profits as taxes which it puts together from enterprises and separate citizens (families). In its turn, the profits of citizens (families) consist from wages, which is paid by enterprises which they sell their labour force, and from other sources (dividends, grants, pensions, and others like that). The citizens (families) get medical services immediately from the medical establishments (medical staffs) or through the intermediary organizations. The state and enterprises supply the medical establishments with medicare factors, foremost workers, equipment and medicines through the proper market, where their cost is determined.

It is possible to divide the economic aspects of medicare functioning in the market conditions into two levels: grate- (state and regional), and micro- (patient, medical staff, medical establishment, joint medical establishments).

The volume of assignations which the state must select on medicare, and their part, that goes to the small level; creation of benefits and encouragements for bringing in additional facilities outside the industrial enterprises and some citizens; grant of investments in development of medicare factors; development of methodology and method of pricing in the medicare system; establishment of correlation of medicare factors, estimation from economic positions of the organizational systems of medicare are determined at the grateveled.

Processes of functioning of medical service market are explored on microlevel, definite economic layouts metric within the limits of  medical establishment, in particular correlation of medical service factors, correlation of wages and other charges on medicare, pricing, changes of populousness demand level on the medical services, and others like that. The main purpose at this level there is a satisfaction of optimum necessity of people in medicare depending from the public possibilities and own spiritual necessities and values.

The health service has social, medical and economic efficiency.

The social efficiency of health service consists in that role which it plays in achievement of the primary purpose to which the man aspires – longevity, active vital activity, high quality of life. If man is healthy, his chances for realization of his potential possibilities are the highest, he it can attain all desired. Certainly, that healthy members of society by most measure can assist to its socio-economic progress, that is beneficially reflected on perspectives of development of this society. Criteria of social efficiency of health service are death rate and ordinary duration of expected life. Then lower is death rate and higher duration of people life , more effective is social function of health service.

The medical efficiency of health service consists in diminishment of morbidity of people and consequences of illnesses.  It is conditioned by the positive action of the special medical measures directed to achievement of this aim. Consequently decline of people morbidity and relapses and complications of illnesses is the index of medical efficiency of health service.

The economic effectivity of health service consists in achievement of economic effect and additional production of national product through the recreation and strengthening of health of the main factor of production labour force.

Let’s, admit, through realization of the proper health and medical measures reduction of death rate of workers is attained, their morbidity is lowered, a considerable part of complications of illnesses is warned. It will have such economic consequences:

– making an additional product for that time during which the life of people is lengthened and  their morbidity is lower;

– reduction of charges on the social security and public welfare through the decline of temporal and firm loss of capacity;

– achievement of the economy of charges on the medical service by  reduction of necessity in it.

Consequently, decline of death rate and morbidity of people brings not only social and medical, but also economic effect. It is measured by difference between losses which inflict death rate and morbidity to conducting prophylactic and medical measures and after their conducting.

The large economic value has a rational use of material resources of the medicare system, foremost labour of medical workers and use of bed fund. Medical workers are basic factor of production of medical services like commodity. The norms of labour expenditures of medical workers exist. They include number of sick whom the doctor or medical assistant must adopt on the ambulatory reception, number of sick, who get a stationary help, inspection norms and medical treatment of sick daily is to be given. Those norms were developed on the basis of the special scientific researches and their approbation in practice. Norms are periodically looked through. Consequently there is a possibility to compare the actual work of medical assistant or doctor with normative and determine function of medical worker.

 

Function of medical worker ₌                     Number of actually  accepted sick  х 100 (%)

in out-patient’s clinic                      Number of normative sick

 

If the function is not executed (less than 100%), it results in the direct economic losses, thus charges on wages of medical workers, public utilities, on the equipment and inventory do not thus diminish. If the function is considerably overfulfiled, it also beside the purpose, so far as is reflected on the medicare quality and testifies to the necessity of revision of norms. Consequently it is necessary to aim to 100%-oho implementation of function which results in most economic and medical effect.

The main thing facilities (more than 70%) are used maintenance of stationary help. Thus it is important, that beds in the permanent establishment were constantly busy by sick, that is executed their function. A bed function or his middle employment is determined as:

 

Number of bed-days conducted by sick in the permanent establishment for year_______________________________

Bed function =      Number of beds in the permanent establishment

 

A part from the division is to make 340 days in a year. It is an optimum index. Difference (365-340) in that is 25 days. There are the days, when a bed is revolved (that is one sick changes other). If bed works less then 340 days, that is not busy by sick, the hospital has direct economic losses, is far as all facilities, except of assignations on the medicinal medical treatment and feed of sick, all equally are expended. If bed works more than 340 days for year, it is also badly, because it testifies of congestion of sick and disparity of their present number to the necessity. It is negatively reflected on quality of maintenance of sick. In such case it is necessary to specify the necessity of population in the hospital beds.

Let’s define the bed necessity for the administrative rural district, that has 80000 of habitants.

Lс = 80 000 х 20 х 15 / 340 х 100 = 706 beds

P = 20 % – nowaday percent of people selection on hospitalization, С = 15 days – middle duration of stay one sick in the permanent establishment.

Consequently for the optimum providing of population of this district in the stationary help 706 beds are necessary.

Market – is a method of labor distribution. For the rational organization of production its planning is necessary. It is up to medicare too. Plan is a foresight of future and substituation of its achievement.

In the conditions of the market economy the medical institutions are acquiring much more of the independence in comparison with the times of administrative-commanding system of management.

Business plan is a document, which aims the management of the establishment at reaching certain strategic goals concerning the further improvement of medical aid people.

First the introduction is written. In the introduction the content of the plan, the main tasks, the ways of their realization, the most important financial information and the expected results are defined.

The next step is describing the history of the establishment: the conditions of its foundation, the main stages of the passed way, the explanations why the establishment has become the one it is at the moment.

The next part of the business plan is the characteristics of the usage of hospital and dispensary medical service. It is essential that the reliability of statistic data concerning activities of the medical establishment should be analyzed, shortcomings and the ways of their elimination should be pointed out.

The next step is the analysis of the area the medical establishment is situated in, the description of the population and other institutions, which are located there. Here the detailed description of the demographic situation in the serviced  area is given: the need in the medical service and dividing this service between this establishment and other institutions, situated in the same area. Considerable role has the detailed characteristics of the financial possibilities of the establishment, precisely – the expected funding from the budget and other sources, the main of which is the people’s insurance. A very important task of this part of the plan is the determination of the cost of the health service provided, setting as the aim attaining the best results with the least expense possible.

The next part of the plan is the consideration of the possibilities of the medical establishment’s reconstruction. The reconstruction must be financially substantiated.

Next goes the economical analysis, which is the comparison of the cost of medical services with the possible financial expenditures of the establishment.

The strategic directions and marketing are defined in the next part of the plan, which is considered to be of great importance.

Up to now modern state of the establishment has been characterized mainly. It is time to look at its future, to ground the possible strategic directions of its development. This part of the plan consists, in its turn, of the following subdivisions:

– The development of the strategic directions. Here the analysis is aimed at the defining of various tasks of priority is given, the possibilities, first place financial, of their reaching are defined, the strong and weak points of other institutions in the same area are pointed out, the successiveness of attaining the tasks set is coordinated, means of work with the population are planned;

– The plan of the marketing. Here it goes about the choice of the services and certain programs, the possibility of their usage by the medical personnel, fixing the cost of certain medical services and other possible changes in the process of the plan’s realization, publicity and advertising campaign about the necessity of using the modern medical services;

– Execution of the marketing plan. It is realized via certain goal-oriented campaigns, for instance, providing with  services of obstetrics, first aid, providing with service for patients with diabetes, etc. Permanent control of the afore-mentioned campaigns’ execution must be carried out.

The following part of the plan deals with financial prognosis. The complete list of financial prognosis and predictions concerning the service possible, risks other difficulties and ways to get them about are given here.

Then the plan of establishment’s steps to be taken is related. There must be a detailed plan in stages carefully drawn up, which concerns the measures the medical establishment has to take along with the set dates for their realization  and those appointed in charge of them. Every quarter this part of the plan must be reconsidered, readjusted and renewed with the current state of the execution being taken into consideration.

At the end of the business plan the appendix is added with the concrete calculations, explanations, reference materials, etc.

Till nowadays drawing business plans has not been widely practiced in medical establishments’ activities. At the moment planning is limited by making up the financial plan and the budget, which is based on three documents: the salary tariff, the staff list and the estimate of revenues and expenditures.

The salary tariff is a document, which fixes the number of the establishment’s staff and the salary every employee receives in accordance with his qualification, category, post held, the state of work, etc.

The staff list is a document, which shows the division of the number of doctors, senior, junior and another personnel in accordance with the number of people living on the territory of the establishment’s activities.

The estimate is a budget given in separate clauses. It is the main planning financial document. First its draft is drawn up on the basis of the execution of the previous year plan, changes in the salary tariff and the staff list.

In the fourth quarter of a current year every medical establishment sends the draft of its estimate to the territorial body of the health protection department (in the countryside – to the chief doctor of the central regional hospital, in the city – to the health protection department). The general budget of the medical establishments of the city (region) is made up there, after which it is sent to the city (regional) department of finance. After that the combined budget is sent to the oblast’ department of finance, and the combined oblast’ budget is sent to the Ministry of Finance of Ukraine. The latter considers these budgets, draws up the state budget, and if it is passed by the Supreme Rada to every oblast’ control figures are sent, which accordingly pass all the way back up to the medical establishment. The budgets of medical institutions are passed by the sessions of the regional (city) rada of people’s deputies.

Revenues of medical establishments’ budgets come from two sources: money, given by the city (regional) budget and the special fund of the additional means earned by the medical establishment. In accordance to “The Law of Ukraine about the local authorities” every medical establishment has got the opportunity to earn the additional means by the foundation on its basis co-operatives, small businesses, joint-stock companies, LTDs, separate enterprises, etc. The activities of all these subdivisions are based on legal grounds and the establishment is to act in the limits of the valid legislation.

Revenues of the budget are divided between the following accounts of the estimate:

1. Salary account. The means for paying the employees’ salaries are put down to it including:

a.Collection to the obligatory state pension insurance (provision);

b.Collection to the obligatory social insurance.

2.       Current account, which accumulates money for economical, municipal, medicine needs, etc.3.          Account for special means (leasing expenditures, paid services).

4.       Commission sums (this account accumulates sponsors’ and charitable contributions). Spending this account’s means is based on “Establishment Regulations”. “Regulations” is a yearly-confirmed document, which defines the expenditures the means of this account can be spent on. As a rule, the establishment has the opportunity to spend this money on salaries, food, medicines, repairs, etc.

5.       Chornobyl’ account. The means of this account for the employees of the establishment, who took part in the elimination of the consequences of the breakdown at the Chernobyl’ nuclear power station, is given from the state budget.

The expenditures’ part of the estimate includes the following points:

1. Current expenses:

a)Payment for the work of the budget establishments’ employees;

b)Setting down to the salary;

c)Purchase of the provision things and materials, keeping the budget establishments;

d)Payment for the municipal services, electricity, etc.;

2. Capital expenses:

a)Capital reconstruction (purchase);

b)Capital repairs, reconstruction;

c)Purchase of equipment and objects of the long-term usage, etc.

3. Undivided expenses.

4. Crediting including the percentage rate.

5. Budget payments:

a)Taxes and obligatory payments (except the income tax and the added value tax);

b)Income tax;

c)Added value tax.

It should be mentioned, that the means set down to the salary, can be spent with this aim only. A person in charge has the right to use it io other way.

Nowadays the necessary funding has, in fact, only one point of the expenditures’ part of the estimate, precisely – current expenses, which include paying for the work of the employees and for the municipal services, electricity. Other points of expenditures lack sufficient funding, money for the capital expenses (capital reconstruction, repairs, reconstruction, purchase of equipment) is not given at all. It makes the one in charge look for additional means and increase the special fund.

 

5. The conception of the health protection reform in Ukraine

1. The main foundations of the organization of the medical aid in Ukraine in the conditions of the market economy.

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 USA, the share of the state in the health care expenditures is lower than 75%.

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 Ukraine is to preserve the prevailing state character.

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 Ukraine must be economically and socially effective. Not only the lack of funding, but also the economical ineffectiveness have become the reason of today’s falling into decay, and getting out of it without the support of the economical laws is impossible. The Soviet system did not acknowledge the value of medical aid, that is why it was funded not because of the objective economical considerations, but of good will only.

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 Ukraine must be based on these main theoretical principles:

– 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 Ukraine achievements of the world theory and practice of the medical aid organization and management.

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 Ukraine has. In the process of addressed and prophylactic observations 1200 diseases are registered yearly for every 1000 residents. The need in diagnostic, treating, and rehabilitation measures must be made more exact, as in the Soviet conditions there were suggested wide-scale programs of hospital treatment without the evaluation of their cost, and the medical world was never cautioned of the necessity of reaching the highest effectiveness with the lowest expenditures possible.

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 Ukraine must be oriented towards in the decades to come. Of course, 10%, as it is written in “Foundations of the legislation of Ukraine about the health protection” is better, 15% spent by the USA is even better, but for Ukraine it is that intention, which for a long time has remained unfeasible.

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.

The salary must comprise no more than 15-20% of the general expenditures on the medical aid. Then the patient will have not only somebody to treat him but also the medicine to be treated with. Nowadays the structure of expenditures on the medical aid is not proportional because of the high share of electricity expenses, which in fact remain unpaid. The nearest future is to bring the final corrections in the structure of expenditures, but it has no considerable influence on the salary in comparison with other expenses. Neither the growing of the gross national product influences it, because it will be accompanied by the increasing the average salary rate of workers of all the fields.

There also exists the necessity of scientifically grounded calculations of the need in the medical personnel and the correlation with other factors of medical aid, which can and must be funded by the state.

Reconstruction of the organizational structure of the health care system.

First place it concerns the primary level or the foundation of the health care system. In fact in the today’s system this foundation is absent, the district service embodies it, though it has no independent status being only the part of the secondary level and also divided between a number of specialists (district pediatrician, teenagers’ doctor, district therapeutist, shop doctor etc.). The specific share of the first medical-sanitary aid in the general amount comprises from 5% to 20%, a district doctor has turned into a controller who distributes patients into the consulting rooms of so-called “narrow specialists”.

A doctor of general practice or a family doctor must embody the primary level; he must solve 90% of all the problems of medical provision of the population.

In order to do this he must be properly trained, have the appropriate office for his work, be technically equipped, and have juridical and financial independence. People must be free to choose this doctor. Calculations show that the number of patients of the general practice doctor or family doctor can fluctuate from 1900 to 3800 persons. In the case when the number of patients is less than 1900 persons,the competition about the open vacancy is announced, 3800 is the upper limit. The wages depends upon the number of patients. He must have the right to hire assistants, the number of which  influences upon the wages too.

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 Ukraine foreign experience being taken into consideration requires the elaboration of the model of social-psychological portrait of  doctor-specialist who is able to work in the market economy conditions. In its turn the above-mentioned requires “extending” the sole ideological chain of the higher medical education from a first-year student to a doctor-specialist as a consumer of knowledge of post-graduate system of education.

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 Ukraine in recent years, and also considerable increasing the number of students at the institutes of the Ministry of the health protection make impossible any qualitative changes in the system of medical aid.

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 Ukraine, there remain a considerable number of medical staff and hospital beds. Public and private medicine is to be created on the basis of these resources in the health care system. This makes a new task, which in the scales of its solving has had no precedents in history of native medicine.

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.

 

Health is the biggest society and individual value, because it to a great extent influences processes and results of economic, social and cultural development of the country, demographic situation and state of national safety ness, it is the important social criterion of the degree of development and prosperity of society.

During today’s lecture we shall characterize the following states of giving Medicare to the population, which need difficult and special approaches.

So, according to the WHPO, secondary Medicare is the aid, that needs the service of the special character, more refined and difficult, than the aid, which is given by a general practitioner; includes the aid that is given by the specialized services according to direction of primary branches of medical service.

In „The bases of Ukrainian legislation of health care” the secondary Medicare is interpreted, as the specialized treatment-prophylactic aid that is given by doctors that have the proper specialization and can provide more skilled consultation, diagnostics, prophylaxis and treatment, than general practitioners.

Such a difference in the interpretation of the secondary Medicare in „The bases of Ukrainian legislation” and WHPO is explained by the fact, the quantity of the general practice doctors and family doctors is not enough yet, theraputists are wordily in the primary branch mainly.

The secondary Medicare in towns is provided by the city many-types incorporated hospitals and medical sections, in villages there are central district and district hospitals.

City hospitals provide about the third part of given Medicare.

Greater part of the city station establishments is united with policlinics, but the independent specialized hospitals also exist.

The main tasks of city hospital are:

– giving of the specialized round-the-clock stationary aid in a sufficient quantity;

– approbation and introduction  of modern methods of diagnostics, treatment and prophylaxis;

– complex treatment;

– examination of disabled;

– hygienically education of population.

The power of hospital establishment is determined by the number of existing beds.

Depending on the number of beds we can determine the staff of different services of doctors, middle medical personnel.

For the giving of the secondary Medicare to the urban population by the order of MPO of Ukraine № 33 from 23.02.2000 year the posts of personnel are set depending on the number of beds.

The number of beds for a 1 wage of a doctor hesitates from 12 (hematological) to 40 (tubercular, for patients with osteoarticular tuberculosis).

Let’s consider some shortly:

15 beds for 1 wage of a doctor are characterized for obstetric (accoucheurs-gynaecologists), allergists, cardiology (department of heart attacks), neurological department for neurologists, doctors-neuro-surgeons, surgeons.

20 beds for 1 wage of a doctor – gynecological gastroenterology, infectious, neurological, oncologic, orthopedic-traumatology, otorunnolaryngology, ophthalmology.

Except of the basic specialists the posts of doctors of other specialities are additionally entered in some departments (ieurological for patients with violation of cerebral circulation of blood is 1 post of doctor-internist for 60 beds, in proctological – 0,5 wage of doctor-oncologist).

The post of diagnostic and medically-auxiliary services, roentgenologists, endoscopists, laboratory assistants, doctors-physiotherapy and other are also set.

Depending on the number of beds in the department, the posts of managers of department are set:

– 60 (9 types is therapeutic, neurological, surgical, cardiologic, traumatological);

 – 50 (6 types is cardiac surgery, dermatovenereological, tubercular);

– 40 (14 types is gastroenterology, cardiologic and other);

– 25 (3 types – thoracic-surgery, obstetric, observative, pathologies of pregnancy).

Posts of the middle medical personnel depend on the number of beds and system of service for patients (two-three leveled).

At the three-leveled system  doctor, middle and junior medical personnel are involved.

At the two-leveled system  doctor and middle medical personnel.

24 hours’ sisterly post  is set: at least – 10 beds at  the three–leveled and 8 beds at the two-leveled  system in the infectious box department and for patients with neuro-infections.

Maximal number of beds – 40 at the three–leveled  system and 30 at the  two-leveled system in dermatovereological, endocrinology, tubercular-pulmonary departments.

Except of chamber, the following posts of such nurses are set:

–         operating-room;

–         bandaging;

–         of the dietary feeding;

–         medical sister for organization of individual care of seriously sacking;

–         procedural cabinet;

–         physiotherapy, massage.

 

Shortly we shall consider the structure of establishment of city hospital:

Rhythmical of working of establishment, substantiation of hospitalization, distributing of patients according to the type largely depends on the induction centre.

The induction centre can be centralized, that is the only one station for all establishment, and decentralized. In the first case it provides the structural distributing of patients through all the hospital, in the second – to the separate departments (infectious, obstetric, gynecological).

The induction centre provides the order of direction to permanent establishment and conducts:

–         registration of patients, that come to permanent establishment and leave it, filling the passport part of the in-patient card;

–         establishing of diagnosis;

–         substantiation of hospitalizations;

–         giving the urgent (aid) aid if it is necessary;

–         sanitary treatment;

–         taking the material for laboratory researches, express-diagnostics, roentgen- and functional researches; determination of type of the specialized department;

–         registration of refusals in hospitalization with determination of reasons;

–         giving the additional information for the hospitalized patients.

To fulfill the work the staff of doctors and middle medical personnel is set.

In the induction centre a doctor get acquainted meets with the facts of medical documents, makes an examination, gives necessary urgent aid and sends a patient to the proper department.

Different specialized departments can exits in city hospitals; it depends on the power of the hospital, presence of doctors in the town, and on distributing of departments between city and district hospitals.

These are mainly: therapeutic, cardiologic, surgical, traumatological, otorunnolaryngological departments. The set of departments is not regulated by the legislation.

Every stationary department consists of chambers and other premises for medical and economic aim (operating block, bandaging, cabinet for manipulations, intern, cabinets of the Head of the department and of the senior nurse. In order to isolate pations in the infectious hospitals the boxes are prepared.

By the order № 303 MPO of Ukraine from October 8, 1997, in the establishments treating and prophylactic of the subsections of anesthesiology and reanimations must exist. They must include such services:

–         department of intensive therapy;

–         anesthetic group;

–         department of intensive therapy, which is strictly specialized.

A manager who is appointed according to the manning table heads the stationary department.

The department of rehabilitation is organized in some many-profiles (types) city hospitals. Such departments are needed at the strictly specialized Medicare that is called tertiary today.

The secondary specialized treatment-prophylactic aid to the rural population is given in district medical establishments.

The leading establishments are central district hospitals that also carry out a role of organizationally medical centers in organization and quality of giving the Medicare.

A Head of the CDH is the chief doctor, who is also the chief doctor of district. He carries out the common guidance of the health care he is responsible for organization of Medicare, for medically-diagnostic, prophylactic, administratively-economic and financial activity of the hospital.

Such assistants aid a the chief doctor:

–         in  medical part;

–         in medical service to population of the district;

–         in examination of temporal disabled when there are not less than 25 medical posts at the ambulatory reception;

–         in the protection maternity and childhood;

–         manager of policlinic.

Assistant of the chief doctor in medical part: directly manages the medically auxiliary and diagnostic departments of permanent establishment. He is responsible for organization and quality of medically-diagnostic process in permanent establishment, for conducting of registration documents, examination of temporal disabled, for observation of sanitary and epidemiological norms and rules, analyses the activity of subsections of permanent establishment.

Assistant of the chief doctor in examination of temporal disabled: is responsible for organization and realization of all measures for conducting an examination. He controls the substantiation and rightness of delivery and continuation of medical certificate, analyses morbidity with temporal disability at the enterprises attached to the policlinic and terms of delivery of medical certificate, and also studies the cases of divergences of examinational decisions of the MCC (Medical-consultative commission) and MSEC (Medical sanitary expert commission).

The chief medical sister of hospital is directly submitted to the chief doctor and his assistant of in medical part. She organizes and controls the work of middle and junior medical personnel, by the aid of the doctors she carries out the measures for raising of it’s qualification, heads the Council of medical sisters of the hospital, controls the rightness of registration, distributing and storaging of medicines, bandaging material.

 

The basic tasks of CDH are:

–         direct giving of primary ambulatory-policlinic aid to the population of district centre and attached area;

–         giving of the specialized ambulatory-policlinic aid to all the population of the district;

–         giving of the specialized stationary aid to all the population of the district;

–         providing quick and urgent Medicare to population;

–         introduction into the practice of the district’s TPE* of work modern methods and facilities of prophylaxis, diagnostics and treatment;

–         organization of consultative aid;

–         organizationally-methodical guidance of the work of all district’s TPE, and also control work of their activity;

–         development and introduction of measures which are directed to upgrade the quality of medical providing;

–         development, organization and realization of measures which can raise qualification of medical personnel; rational usage of medical personnel’s and materially-technical resources;

–         planning, financing and organization of the materially-technical support of the district’s health care establishments;

–    qualification raising of medical staff of the district and section TPE.

 

*TPE – treatment-prophylactic establishments

Sometimes often on the joint of large in territory and remote from a regional center the specialized inter-district departments are made (created) which give specialized aid, lead consultative reception of the sick peoples from attached  territories.

Structure of central district hospita

l

The informationally-analytic departments, which analyze the indices of health of population, indices of work of the TPE district, are created in each CDH. They plan and organize visits of specialists of rural areas for the consultative aid to the population and doctors; they organize treatment-prophylactic aid in a district. District (chief) specialists get busy of this work, duties of which are carried out by experienced doctors. Together with an analytical department they estimate numerous information about indices of health of the population.

 

Tertiary Medicare

WHPO gives to it such determination: it is the aid, that needs highly skilled service, which as a rule can be given only in the centers and hospitals which passed the proper specialization and are specially equipped to that aim.

According to the „Bases of Ukrainian legislation of health care” the tertiary medically-sanitary aid (MSA) is given by a doctor or a group of doctors who have the proper preparation in the field of diseases which are difficult for diagnostics and treatment, in the case of treatment of illnesses which need the special methods of diagnostics and treatment. And also with the purpose of establishment of diagnosis and conducting of treatment of diseases which are rarely met.

Regional medical establishments belong to the centers of tertiary Medicare in Ukraine. These are many type and specialized hospitals, specialized dispensaries, republican specialized centers of medical aid.

These establishments differ by much better material and technical providing and complication of structure and functions.

Two functions of these establishments are considered to be basic:

–         organizationally-methodical guidance of the secondary level of MSA;

–         giving to the patients highly skilled and strictly specialized Medicare.

Structure of establishments of tertiary MSA consists of administrative and executive branches.

An administrative brand includes a chief doctor, his assistants, chief accountant, managers of the specialized departments and services, which carry out the duties of supernumerary specialists which are responsible for development of the services in the region, chief medical sister, managers of the departments and services of establishments and their senior nurses.

Additional subsections are made of organizationally-methodical departments and cabinets, book-keeping, engineering service, library with the group of scientifical-medical information.

Consultative policlinic is the separate structural subsection of establishment of tertiary MSA. The narrow specialized departments of permanent establishment, auxiliary treatment-prophylactic subsections, clinical, biochemical and bacteriological laboratories, separations of functional diagnostics, path anatomical, physical therapy and radiological departments) are obligatory.

The departments of the planned and urgent Medicare are special services of the regional hospitals.

We will consider the task and functions of some subsections of the tertiary branch of MSA:

The consultative policlinic of regional hospital conducts:

–         giving of highly qualified consultative aid to the patients after directions of treatment-prophylactic establishments of the region;

–         engages in consultation highly skilled doctors-specialists of the hospital and other TPE, and also workers of research institutes and medical institutes;

–         Sends the conclusions of the results of consultations to TPE;

–         develops for the TPE region the order and demonstrations for direction of patients to the consultative policlinic;

–         organizes and conducts out of clinic consultations of doctors-specialists in districts, and also consultations by correspondence for the doctors of the region’s TPE;

–         conducts the systematic analysis of cases of disagreements of diagnoses between TPE, which have sent the patients to the consultation and consultative policlinic at the districts of the region ;

–         analyses the errors assumed by doctors TPE at the inspection and treatment of patients before directing them to the consultative policlinic;

–         it is responsible for the informational providing about the news of modern methods of treatment and diagnostics in districts and TPE of the region.

The department of urgent and planly-consultive aid is other important structural unit of the regional hospital. In its structure there is a 24-hour’s dispatcher service of reception and registration of calls from the hospitals of districts and cities of the region. The specialists of regional hospital and other TPE regions employees of higher medical institutes, research institutes are attracted, to the giving of urgent and planly-consultive aid on the agreement with the corresponding establishments and institutions. To engage into this work employees, the special order is given out at the Management of health care.

Doctor giving the necessary Medicare in the place, and in the case of necessity transports a patient to the regional center, and on some occasion outside a region to the corresponding TPE.

Both sanitary aviation and ground vehicle is used to that aim, depending on the state of patient, distance, meteorological conditions, season, time of the day.

The same department provides the delivery of necessary medical loads donor blood and its preparations, canned organs and tissue, medicines to the districts and cities in the case of necessity.

Organizationally-methodical work is conducted at the level of establishments of tertiary level. It consists of the following sections :

The network of the independent specialized establishments-dispensaries belongs to the specialized establishments tertiary Medicare.

A dispensary is an establishment, the ambulatory and stationary aid at the certain diseases appears in which (tuberculosis, venereal illnesses, psychical, endocrine diseases and other).

According to the ratified list of establishments of health care there are 11 types of type dispensaries in Ukraine.

Dispensaries consist of policlinic (clinical separation) and permanent establishment.

During the organization of work of these establishments the features of every dispensary are taken into account. They are determined by etiology, clinic, epidemiology of concrete diseases.

Principles of work of all dispensaries are equal and consist in:

–         active systematic supervision after contingents and giving the skilled Medicare;

–         supervising after contact people;

–         conducting of prophylactic measures and hygienical education of population;

–         studying of morbidity in the district of activity;

–         developing of preventing measures of against appearance of pathology;

–         giving of consultative aid to the doctors of other medical establishments;

–         controlling the completeness registration and on time signalization when a patient is revealed.

The medical card of out-patient and checking card of clinical supervision  are the basic registration documents in dispensaries.

The last of them aids to control the on time of visits, passing of medical examination, fulfilling of the appointed treatment, health measures and employment.

Now we will shortly describe the activity indices of permanent establishments, as the main branch of the secondary and tertiary medically-sanitary aid to the population, according to which the medical work is estimated. These indices  characterize:

–         guarantee to population the stationary aid;

–         the job of the medical personnel;

–         materially-technical support;

–         usage of bed fund;

–         quality of stationary Medicare and its efficiency.

Calculate:

1.     Average annual occupation of bed:

 

 

2.     Middle duration of the staying of a patient in a hospital:

 

 

3.     Circulation of bed (middle number of patients which were on a bed):

 

 

Indices are calculated for the whole permanent establishment, and also for all his departments.

Activity of doctors is calculated separately:

For example:

а) middle number of operations for one occupied post of surgeon:

 

 

4.     Index of lethality (it is calculated in %):

 

 

b) after operational lethality is determined separately:

 

 

The analysis of activity of medically-auxiliary subsections is conducted in relation to in-patients:

Number of physical therapy procedures

Number of persons who left the permanent establishment

 

 

 

For example:

 

Activity of other subsections is estimated in the same way (MRT – therapy, x-ray photography of laboratory, laboratories and other).

However, speaking about the secondary and tertiary branches of medically-sanitary aid, it should be said, that for today even the tertiary level of Medicare occupies high enough percent, and exceeds the extent and tasks which stand before it. It is conditioned by that, medical establishments of tertiary level often carry out the functions of the secondary and even primary for in the habitants of regional center and nearest settlements. According to statistical information, up to 80 % visitors of consultative policlinic and 60 % of hospitalized are the habitants of regional center. It confirms the necessity of radical changes in organization of Medicare.

Two directions of structural rebuilding of stationary aid are offered for today, strategy of which consists in the solving of two connected tasks:

1) Diminishing of levels of hospitalization by substitution relatively expensive stationary treatment by more effective and economically advantageous types of Medicare;

2) Increasing of efficiency of the usage of bed fund.

І. The first task is necessary to decide by:

а) the improvement of on time and quality of primary medically-sanitary aid;

b) substitution of hospital aid by ambulatory as a result of application of modern effective pharmaceutical facilities;

c) widening of the system of home treatment, first of all patients of old years and invalids;

d) developing of alternative types of treatment as daily and home permanent establishments, ambulatory centers in surgery;

e) the increasing of threshold levels in hospitalization by organization of departments for the short-term supervision after patients in older to have a possibility to make a decision about hospitalization in doubtful cases.

ІІ. For the increasing of efficiency of the usage of bed fund is necessary:

1) conducting of structural transformations in the system of stationary aid, oriented on the increasing of functionality of the usage of bed fund and forming an optimal territorial network of stationary establishments;

2) change of the legal status of hospital;

3) introduction of the effective systems of financing of stationary aid;

4) improvement of integration between permanent establishments, primary and social.

Structural rebuilding of stationary sector includes:

– differentiation of bed fund in accordance with intensity of treatment and nursing;

– concentration of highly-specialized hi-tech aid;

– forming of common medical space and liquidation of the administration systems of medical service of some contingents of population.

 

Today we discussed the secondary and tertiary level of Medicare, and strictly define the size of the aid in city hospitals, district (ІІ level) and regional (ІІІ level) hospitals. However in practice a substantial difference between the ІІ and ІІІ level in Ukraine doesn’t exist.

According to the generally accepted criteria of observance of hierarchical of hospital aid, the high indices of turn of resources and short terms of staying of patients must be in the hospitals of the secondary level and long terms in the hospitals of tertiary level.

The existent index of the TPE II level testify about unsatisfactory organization and quality of treatment in the hospitals of such type, and relatively short terms of patients staying in regional hospitals that we can consider that greater part of their patients does not need treatment in establishments of such type.

At such organization of the work the cost of stationary aid grows in general and availability of aid of tertiary level gets worse, although there must be concentrated hi-tech and highly-specialized aid and proper technical equipment.

To increase the efficiency of functioning the MPO of Ukraine plans to give to the hospitals the status of state enterprises with giving of them certain administrative and economic autonomy. It will give the possibility to decrease the number of limitations in activity of establishments, which are traditionally met at TPE.

The MPO plans to conduct reorganization and reformation of stationary aid in Ukraine in a few stages.

At that:

І. On the first stage to carry out:

–         development of the criteria (indices) of hospitalization and leaving of patients from stationary establishments (departments) of different intensity;

–         to define the optimum level of hospitalization in permanent establishments of intensive treatment, permanent establishments for treatment of chronic patients, hospital of sisterly nursing;

–         to define the necessities of population in hospital beds in accordance with the level of intensity of medical service;

–         it is necessary to review the table equipment and norms of loading of medical personnel, coming out of multilevel organization of stationary aid;

–         to conduct licensing of medical establishments independently of forms of ownership, with determination of those types of Medicare, for the giving of which they have corresponding conditions;

–         to develop the plans of gradual transition to the multilevel system of stationary service;

II. On the second stage it is necessary to take into account the factor of availability of stationary aid (character of settling, transporting availability), formed habits of population to the place of reception of services. Thus it is needed to foreseen:

–         gradual transmission in community property of administrative medical establishments;

–         territorial integration of hospitals of different subordination;

–         diminishment of number and strengthening of hospitals, the urgent stationary aid are given in which;

–         reorganization some of the hospital powers into establishments (departments) for chronic patients, establishments (departments) for giving of medically-sanitary aid – sisterly nursing and other.

–         concentration of hi-tech highly-specialized aid at regional level;

–         introduction of the system of the complete providing of quality of medical service; it is accreditation of hospitals, internal systems of control, clinical protocols;

–         development of services (social aid and increase of its availability), improvement of co-ordination between the sector of health care and social sector.

III. It is necessary on the third stage:

–         complete transition to the multilevel system of stationary service;

–         completion of forming of common medical space for giving of Medicare;

–         exposure of surplus hospital powers and establishments which do not complete modern standards and their next closing.

 

POWER POINT

                      I. Importance of Understanding Organizational Structure of Hospital

                      A. facilitates the understanding of the hospital’s chain of command

                      B. shows which individual or department is accountable for each area of the hospital

                      II. Complexity of Organizational Structure Depends on Size of Healthcare Facility; large acute care hospitals have complicated structures, whereas, the smaller institutions have a much simpler organizational structure

                      III. Grouping of Hospital Departments Within the Organizational Structure

                      A. Although each hospital department performs specific functions, departments are generally grouped according to similarity of duties.

                      B. Departments are also grouped together in order to promote efficiency of the healthcare facility.

                      C. Common organizational categories might include:

                 1. Administration Services (often referred to simply as “administration”)

                 2. Informational Services

                 3. Therapeutic Services

                 4. Diagnostic Services

                 5. Support Services (sometimes referred to as “Environmental Services”)

                      IV. Administration Services—business people who “run” the hospital

                      A. Hospital Administrators

                 1. manage and oversee the operation of departments

                   a. oversee budgeting and finance

                   b. establish hospital policies and procedures

                   c. perform public relation duties

                 2. generally include: Hospital President, Vice Presidents, Executive Assistants, Department Heads

                      V. Informational Services—documents and process information

                      A. Admissions-often the public’s first contact with hospital personnel

                 1. checks patients into hospital

                   a. responsibilities include: obtaining vital information (patient’s full name, address, phone number, admitting doctor, admitting diagnosis, social security number, date of birth, all insurance information)

                   b. frequently, admissions will assign in-house patients their hospital room

           B. Billing and Collection Departments – responsible for billing patients for services rendered

           C. Medical Records – responsible for maintaining copies of all patient records

           D. Information Systems – responsible for computers and hospital network

           E. Health Education – responsible for staff and patient health-related education

           F. Human Resources – responsible for recruiting/ hiring employees and employee benefits

            VI. Therapeutic Services – provides treatment to patients

           A. includes the following departments:

           1. Physical Therapy (PT)

           a. provide treatment to improve large-muscle mobility and prevent or limit permanent disability

           b. treatments may include: exercise, massage, hydrotherapy, ultrasound, electrical stimulation, heat application

           2. Occupational Therapy (OT)

           a. goal of treatment is to help patient regain fine motor skills so that they can function independently at home and work

           b. treatments might include: arts and crafts that help with hand-eye coordination, games and recreation to help patients develop balance and coordination, social activities to assist patient’s with emotional health

           3. Speech/Language Pathology

           a. identify, evaluate, and treat patients with speech and language disorders

           b. also help patients cope with problems created by speech impairments

           4. Respiratory Therapy (RT)

           a. treat patient’s with heart and lung diseases

           b. treatment might include: oxygen, medications, breathing exercises

           5. Medical Psychology

           a. concerned with mental well-being of patients

           b. treatments might include: talk therapy, behavior modification, muscle relaxation, medications, group therapy, recreational therapies (art, music, dance)

           6. Social Services

           a. aid patients by referring them to community resources for living assistance (housing, medical, mental, financial)

           b. social worker specialties include: child welfare, geriatrics, family, correctional (jail)

           7. Pharmacy

           a. dispense medications per written orders of physician, dentists, etc.

           b. provide information on drugs and correct ways to use them

           c. ensure drug compatibility

           8. Dietary – responsible for helping patients maintaiutritionally sound diets

           9. Sports Medicine

           a. provide rehabilitative services to athletes

           b. teaches proper nutrition

           c. prescribe exercises to increase strength and flexibility or correct weaknesses

           d. apply tape or padding to protect body parts

           e. administer first aid for sports injuries

           10. Nursing (RN, LVN, LPN)

           a. provide care for patients as directed by physicians

           b. many nursing specialties include: nurse practitioner, labor and delivery nurse, neonatal nurse, emergency room nurse, nurse midwife, surgical nurse, nurse anesthetist

           c. In some facilities, Nursing is a service in and of itself.

            VII. Diagnostic Services – determines cause(s) of illness or injury

           A. includes the following departments:

           1. Medical Laboratory (MT) – studies body tissues to determine abnormalities

           2. Imaging

           a. image body parts to determine lesions and abnormalities

           b. includes the following: Diagnostic Radiology, MRI, CT, Ultra Sound

           3. Emergency Medicine – provides emergency diagnoses and treatment

 

            VIII. Support Services—provides support to entire hospital

           A. includes the following departments:

           1. Central Supply

           a. in charge of ordering, receiving, stocking and distributing all equipment and supplies used by healthcare facility

           b. sterilize instruments or supplies

           c. clean and maintain hospital linen and patient gowns

           2. Biomedical Technology

           a. design and build biomedical equipment (engineers)

           b. diagnose and repair defective equipment (biomedical technicians)

           c. provide preventative maintenance to all hospital equipment (biomedical technicians)

           d. pilot use of medical equipment to other hospital employees (biomedical technicians)

           3. Housekeeping and Maintenance

           a. maintain safe clean environment

           b. cleaners, electricians, carpenters, gardeners

            IX. Traditional Organizational Chart:

 

 

Teacher Instructions:

Symbolic Drawing of Organizational Structure of Hospital

Materials:

colored markers or colored pencils

white butcher paper (3 x 2’) or poster board

Goals:

-promotes team work

-encourages students to execute logic and problem solving skills

-makes use of collective innovative thought and creativity

Steps:

1. Using the Organizational Structure Pyramid, show the students how a hospital’s organizational structure can be demonstrated in a non-traditional way. (I usually draw a replica of the pyramid on the board for the entire class to view.)

2. Discuss the hierarchy of the structure and its relationship to occupational status, length of training, annual income, etc.

3. Divide students into groups of 4 to 5.

4. Each group gets a piece of butcher paper and colored markers.

5. Instruct the students to think of a symbolic way in which to represent the organizational structure of the hospital. Here is a simplistic example to get them thinking:

tree in a field: ground represents support services

trunk of tree represents administration services

sun in sky represents information services

main branches represent diagnostic services

leaves represent various therapeutic services

6. Each department and service should be labeled.

7. Tell students that they must be able to explain why they think their drawing symbolically represents each service.

See Power Point for examples

 

Four Corners of Practice

Teacher Instructions

                      1. Students are seated in groups of four. On a large sheet of paper (like butcher paper) have the students:

                      a. Write personal information on each corner: name, career choice, educatioecessary, expected job description (what would happen during an ordinary day at work.)

                      b. Discuss the four individuals represented on the corners of their paper, and then invent a patient scenario in which each could be professionally involved.

                      c. Compose a story about the patient in which they can each attend in the roles they have chosen for themselves. This story should tell how each professional would care for the patient and the implications of the situation to each of them.

                      2. Students will prepare posters or PowerPoint presentations to illustrate the teamwork

                      3. Students will present their work to classmates

 

Destination of annual report of hospital establishment:

–                       exposure of positive and negative sides of establishment activity and their reasons;

–                       determination of power, staff providing and types of help;

–                       estimations of health of population (partly) – with the diseases;

–                       planning of measures of the medical providing of population in the district of service.

Order of making and giving the annual report.

A report is formed on the basis of primary medical documents, which are filled by a treating doctor during a year (coupon of ambulatory patient, diary of doctor, stat-card of left out from permanent establishment and other) and separately taken forms (summary form about morbidity of population, summary form about motion of patients and hospital fund).

 Report is made by the workers of orgmethodcabinet directly with participation of managers of the separations, leaders of lower links of health care and is given to the higher instances in the set term.

Structure of annual report:

Medically-diagnostic report (f. № 20), includes the list of departments and cabinets treatment-prophylactic establishments situated in the district of service (рrimary care centres, of collective farm houses, medical profilactorium) and consist of the following 5 sections:

–                   staff of the establishment;

–                   activity of policlinic;

–                   activity of permanent establishment;

–                   work of medically-auxiliary departments (cabinets);

–                   work of diagnostic departments.

Addition to the basic report of f. № 12 – contains information about the number and name of diseases of population of different age.

 

PRIMARY REGISTRATION DOCUMENTS WHICH ARE USED DURING MAKING AN ANNUAL REPORT

Medically-diagnostic report (f. 20)

Addition to the report of establishment

Report about the number of the diseases registered at patients (f.12) is filled on the basis of:

а) coupon of ambulatory patient (f.25-7/r)

б) check card of clinical patient (f.030/r)

 

Part І. Staff of the establishment

1.     Manning table

2.     List of the wages for December

 

Part ІІ. Activity of the policlinic

Таble 1 Work of the doctors of the policlinic

1.     Diary of a doctor of the policlinic (f.039/r)

Таble 5 Prophylactic examinations conducted by this establishment

1.     List of persons who are subjected to the special purpose medical examinations (f.278)

2.     List of persons who are subjected to the periodical medical examinations

3.     Card of registration of the center system health (f.131)

Таble 6 Clinical supervision

1.     Summary list of the registration of morbidity (f.271)

2.     Check card of clinical patient (f.030/r)

 

Part ІІІ. Activity of permanent establishment

Таble 1 Bed fund and its use

1.      Summary list of registration of patients’ motion  and bed fund (f.016/r), which is formed from the lists of registration of patients’ motion and bed fund of permanent establishment(f.007/r).

Таble 2  Patients’ structure in permanent establishment

1.     Statistical card of the left out the permanent establishment (f.066/r)

Таble 3  Surgical work of permanent establishment

1.     Statistical card of the left out the permanent establishment (f.066/r)

Таble 4  Urgent surgical help

1.     Statistical card of the left out from permanent establishment (f.066/r)

 

Part ІV. Work of medically-auxiliary departments (cabinets)

Activity of physical-therapeutical department (cabinet)

1.     Card of patient who was treated in the physical therapy department (cabinet) (f.044/r).

 

Part V. Work of diagnostic departments

Activity of roentgenologic department:

1.     Dairy of registration of roentgenologic researches  (f.050/r)

2.     Diary of registration of work of roentgeno-diagnostic department (f.030-5/r)

 Laboratory activity:

1. Dairy of registration of the analyses and their results (f.250/r).

 

Health care reform and healthy lifestyle

HEALTH CARE SYSTEM – MODERN, EFFECTIVE AND AFFORDABLE

What is our present health care system like?

Population decline rate in Ukraine is the highest in Europe.

Average life expectance in Ukraine is much lower than in other European countries, a considerable part of manhood die before retirement age. A half of adult population of Ukraine suffers from one or several chronic diseases. Ukraine’s rates of incidence of cardiovascular diseases, tuberculosis, traumatism, and disability are the highest in the CIS countries.

Rapid growth of disease and disability incidence among school-aged children, non-observance of environmental hygienic standards, unbalanced nutrition and insufficient consumption of maiutrients, macro- and micronutrients, physical inactivity, bad habits (smoking, drinking alcohol, consumption of toxic substances and drugs), early sex and insufficient personal hygiene (spread of sexually transmitted diseases, HIV and tuberculosis) demand to strengthen the preventive trend in working with people, especially children of all ages in order to form healthy lifestyle skills.

The modern medical assistance model is based on the principles introduced yet in the Soviet times. Its main drawbacks are as follows: insufficient quality of medical services, low affordability of medical assistance, inefficient usage of budget funds in the industry, and low level of development of preventive medicine. Despite the most part of early deaths in Ukraine is caused by the diseases that could be prevented or healed, the Ukrainian health care system remains to be focused on the emergency medical aid and treatment of episodic illnesses and is not ready for work aimed at overcoming the mortality crisis. There is neither effective public nor private medicine in our country that evidences that urgent reform in the sector is badly needed.

WHAT SHOULD HEALTH CARE SYSTEM BE LIKE?

For the successful reduction of mortality and morbidity rates, the whole health care system in Ukraine should be reformed from the emergency aid model into a model of integrated patient management which is more suitable for the prevention and control of noninfectious diseases. Medical professionals should identify individuals who are at risk, inform them of the consequences of their inattention to their health, make timely diagnosis and conduct appropriate treatment. Citizens should be aware of their role in making decisions during treatment of chronic diseases. The understanding of the importance of treatment and involvement of patients in selecting an appropriate treatment strategy will contribute to performance of medical prescriptions and reduce the risk of premature death.

The health care system in Ukraine should be reformed according to the following principal directions:

·                     Introduction of new standards in rendering medical services and, accordingly, the criteria of their quality.

·                     Significant modification of the mechanism of financing health care institutions.

·                     Introduction of a system of incentives for improvement of work of health care professionals.

·                     Creation of an effective model of coordination of work of private and public health care institutions.

·                     Putting the emergency aid and priority of primary health care in the forefront.

·                     Structural reorganization.

·                     Effective prevention of diseases of different etiologies, personnel reform and promotion of healthy lifestyle.

Private and public health care institutions should work in the same direction for improving the health of our citizens. Therefore, it is necessary to put them into equal conditions financing the treatment of patients from the budget, regardless of the ownership form of a medical institution.

The main conceptual directions of the health care reform in Ukraine today envisage distribution of responsibilities among the primary (primary medical care), secondary (specialized) and tertiary (highly specialized) levels of medical assistance.

The main tasks in restructuring health care institutions should include carrying out of their inventory and local audit whereupon a master plan of optimization of health care network in each particular region will be developed.

At the primary health care level in rural areas and cities, it is necessary to determine units that are to provide the primary medical care.

At the secondary health care level the network of central district and regional hospitals, central municipal, municipal and district hospitals and independent municipal clinics should be designed in accordance with the needs of the population, territorial accessibility, disease incidence and other criteria. It is reasonable to create a multi-field hospital of intensive treatment that will ensure the provision of specialized medical care as well as entire medical assistance throughout the region.

At the tertiary health care level a highly specialized health care level should function, which will be ensured by regional hospitals, higher medical education institution departments and institutes for scientific research.

The emergency aid in most cases should be provided by medical assistance teams. Ambulances should be equipped according to the table that will ensure adherence to emergency aid provision standard.

Restructuring of the network of medical and preventive treatment institutions will inevitably lead to reforming of their staffing.

The application of medical services quality indicators and standards in the health care reform will significantly improve the quality of accreditation of health care institutions as well as conclusion and prolongation of agreements on the provision of medical services by medical and preventive treatment institutions.

HOW CAN WE ACHIEVE THIS?

The main stroke is against the destroyed health care system and unhealthy lifestyle

The universally recognized direction in qualitative health care reform should be the ensuring of a transparent multi-funding scheme that will enable to solve economic, organizational, personnel and technological problems in the health care field by means of:

·                     Gradual introduction of compulsory public social health insurance (with insurance amounts to be paid by both employers and employees).

·                     Further development of private health insurance.

·                     Creation of a social solidary sector that is a union of municipal medical institutions, medical companies, health care institutions and other legal forms as well as physicians in private practice interconnected by a unified closed diagnostic and treatment technological process of provision of medical services and a unified system of financing from off-budget (insurance, social solidary special purpose financial and charity funds) and commercial sources.

The new model of financing health care institutions should envisage their independence in solving financial and economic issues including staffing level based on the health care needs of the population, material incentives for employees, the possibility to obtain additional financing by means of involvement of donor funds, provision of paid services and other sources not prohibited by the legislation.

The amount of remuneration for medical assistance shall be determined based on the number of patients assigned to each particular doctor. Thus, doctors who have more patients shall receive higher remuneration.

At the primary level in rural areas, it is necessary in the first place to create an available network of polyclinics and outpatient clinics, to open first-aid posts and leave central district hospitals appropriately reequipped.

At the secondary level, each health care institution or first aid post will be financed directly from funds accumulated at the regional level depending on the variety, quality and efficiency of medical services.

At the tertiary level, health care institutions depending on the assigned functions and budget code regulations will be financed from the regional or state budget.

On the basis of child clinics it is reasonable to create health care and diagnostic centers in which physicians of different specialties will remain in the status of first contact experts. Special attention should be paid to the resumption of the improved comprehensive medical care for children in organized groups (preschool institutions, trade schools and comprehensive schools).

Health care reform can be successful only subject to the improved economic situation in Ukraine. We realize that problems in health care field can be solved only subject to changes in the political and economic conditions – shadow economy, total corruption and impoverishment of the most part of the population are by no means able to improve the situation in the health care sphere. That is why compulsory social health insurance for working groups of citizens should be introduced on a stage-by-stage basis. In addition, health care sector reform should start at the top via elite’s refusal to receive free medical services.

Compulsory social health insurance for working groups of citizens will be performed and ensured by the state by means of public health insurance companies that will compete with each other. A patient paying insurance contributions will have the right to obtain a range of medical services determined by the legislation.

For individuals who receive social assistance the state shall remain a main payer of social insurance contributions.

Private health insurance will be performed on a voluntary basis. Public health insurance will be based on the principles of obligatoriness, solidarity, self-government and receipt of medical assistance in kind without direct payment of medical services by patients, all financial transactions being severely controlled by independent organizations.

Health insurance should be introduced based on a clear legal basis regulating the relations “doctor – patient” and “patient – health care institution” where obligations of health care institutions towards patients, legal issues concerning physicians’ practice and patients’ rights should be specifically determined. Mutual obligations of a health care institution and a patient should be specified in a respective agreement signed by a patient before hospitalization.

Choosing healthy lifestyle, safe conduct and personal hygiene, the formation of life skills reducing susceptibility to HIV infection, prevention of psychological disturbances, tobacco smoking and alcohol, toxic substances and drug consumption, formation of reproductive health (and prevention of its loss), healthy nutrition, importance of optimal physical activity and sports are possible due to extensive implementation of outreach programs and interactive forms of work with citizens.

The following basic measures are suggested to be taken for the prevention and control of non-communicable diseases:

·                     Tobacco Control – to ban advertising and raise taxes on tobacco products; to use warning labels with illustrations on tobacco packaging showing the harm to health. To ensure compliance with the ban on tobacco sales to minors and prohibit smoking in public places. To conduct active education in schools.

·                     Alcohol Consumption Control – to apply public service advertising on the consequences of alcohol abuse. To raise taxes on alcoholic products; to ensure compliance with the ban on sales of alcoholic beverages to minors; and ban advertising of alcohol. To conduct active education in schools.

·                     Traffic Safety Compliance – to ensure compliance with the safety belt use requirement; strict observance of laws banning drunk driving with clear definition in the legislation of maximum permissible levels of concentration of alcohol in blood; and upholding of restrictions on speed.

·                     Unhealthy Diet Prevention – to conduct active education in schools, to provide information on the harm of fast food consumption, excessive consumption of fat, sugar and carbonated beverages etc. Initiate participation of social organizations in propagation of healthy diet ideas.

·                     Physical Activity Encouragement – to conduct active education in schools on the benefits of physical activity and sports. To assist sports institutions and clubs, especially those focused on age or gender groups with low level of physical activity. To involve health care professionals into respective educational programs promoting physical activity.

·                     Self Care – to conduct active work in schools to develop incentives for people to control their health, to involve in this process the representatives of social organizations and health care professionals. To facilitate implementation of governmental and non-governmental programs and campaigns to encourage early diagnosis of diseases and work with high-risk groups. To run broad public awareness campaigns. 

Health care programs should include the following principal items:

·                     Rational work-rest regime.

·                     Rational nutrition.

·                     Favorable psychological microclimate in family and at work. 

·                     Hygienic culture.

·                     Optimal active mode of life, regular exercise, hardening procedures; and prevention of bad habits.

Healthy lifestyle should become ideology of upbringing, education, social and sports movements. Conditions for going in for sports must be created at places of residence, study or work.

Healthy lifestyle measures should be taken from the very birth (hardening and infant development programs). Playgrounds, training schools and gyms must be available for everyone. Healthy lifestyle should become popular – prestige to be healthy will be based on social priorities supported by appropriate propaganda, public service advertising and implementation of projects aimed at the formation of a respective public opinion.