Availability and quality of medical care are ensured. Legal support for access to medical care. Main conclusions on the use of measures to increase access to medical care

Assistance should be based on the provision of high-tech care by doctors, preventive measures, accurate diagnosis, conscientious treatment using modern technologies and productive, comfortable rehabilitation.

General components and characteristics of the ILC

In the literature you can find more than one definition of this concept. Many countries adhere to the WHO definition, which states that the quality of medical care is the optimal medical care for the patient’s health in accordance with the current level of medical science, the patient’s diagnosis, his age, and response to treatment. It is important that minimal means are used, the risk of injury and complications is minimized, and the patient must be satisfied with the result of care.

The definition of the Central Research Institute of Health of the Ministry of Health of the Russian Federation is simpler and more understandable. It states that the quality of medical care is the totality of all characteristics that confirm the compliance of the actions of providing medical care with the necessary needs of the population, modern technologies, medical science, and patient expectations.

A standard of medical care is a document that contains a specific list of procedures required to be performed when treating a specific disease or condition.

Characteristics of medical care

The characteristics of the KMP include:

• Professional competence.
• Productivity.
• Availability.
• Interpersonal relationships between patient and doctor.
• Continuity.
• Efficiency.
• Convenience.
• Safety.
• Satisfaction.

Professional competence is understood as the availability of skills and knowledge of health workers, as well as support staff, the ability to use them in their work, in accordance with standards, clinical guidelines, and protocols. Poor professional competence is expressed not only in small deviations from standards, but also in gross errors that can reduce the effectiveness of treatment, which can jeopardize a person’s health and even life.

The accessibility of medical care means that it should not depend in any way on criteria such as social status, culture, or organization.

The quality of medical care will depend on the effectiveness and efficiency of the technologies used in the field of medicine. To evaluate performance, you need to answer 2 questions:

1. Will the treatment prescribed by the doctor lead to the desired result?
2. Will the result be the best in specific conditions if I apply the therapy prescribed by the doctor?

Interpersonal relationships are understood as the relationships between health care workers and patients, medical staff and management, and the health care system as a whole and the people.

Efficiency is defined as the ratio of resources expended to the result obtained. It is always a relative concept, so it is used to compare alternative solutions.

Continuity means that the patient can receive all the necessary medical care without delays, interruptions, or unnecessary repetitions.

Quality control of medical care is ensured by such characteristics as safety. It is understood as reducing all possible risks from a side effect to a minimum during treatment and diagnosis.

Convenience means cleanliness, comfort, and confidentiality in medical institutions. The concept of patient satisfaction includes the fact that the healthcare system must meet the requirements of health workers, the needs, and expectations of the patient.

Review of legislation

The regulations that regulate the quality standard of medical care include:

1. Federal law, which is called “On the fundamentals of protecting citizens in the Russian Federation” No. 323.
2. entitled “On compulsory health insurance in the Russian Federation” No. 326.
3. Order of the Ministry of Health (“On approval of evaluation criteria”) No. 520n.

Federal Law No. 323 contains characteristics of the timeliness of medical care, the correctness of the choice of the necessary treatment method, and the outcome of the achieved treatment result. This law also contains information on the examination of the quality of medical care.

Federal Law No. 326 is intended to regulate the process of monitoring ILC in medical institutions. There are clear rules, forms, conditions and terms for providing medical care. The law applies only to public clinics where the patient receives treatment under the compulsory medical insurance program. In private clinics, the basis of the relationship between the institution and the patient is an individual agreement concluded between them.

The Order of the Ministry of Health is a normative act that defines the standards and criteria that are used in assessing the quality of medical care.

Medical care: quality and evaluation

This issue is regulated under the title “On Compulsory Health Insurance in the Russian Federation” No. 326. According to it, an examination is used to evaluate the IMP, which is divided into planned and targeted.

Targeted examination is carried out in the following cases:

• Complaints from the patient.
• Complications of the disease.
• Unpredictable death.
• In some individual cases, when a patient with the same diagnosis re-applies.

As for the planned examination, it takes place according to a previously planned schedule, which is drawn up by interested organizations - compulsory medical insurance funds. This type of assessment should be applied to at least 5% of cases of medical care for the entire reporting period.

Only compulsory medical insurance funds and insurance organizations are required to carry out an examination of the quality of medical care. Speaking on their behalf, the examination is carried out by experts who meet the professional requirements regulated by law:

• Minimum 10 years of experience.
• Higher education.
• Accreditation of a medical expert.
• A physician's position in a specific area of ​​need.

An expert doctor evaluates the accuracy of medical documentation, its compliance with legal requirements and its possible impact on the patient’s condition. They consider the correctness of the diagnosis, the timing of treatment and the final result.

ILC Department

In order to properly organize the functioning of the healthcare system, there are special organizations that provide medical care based on meeting the necessary needs of patients. These organizations exist on the basis of a state program to guarantee the provision of free medical care to all citizens of the Russian Federation.

The medical care quality control system is based on the principles:

• Continuity of management.
• Using the achievements of the evidence base of medicine.
• Conducting examinations based on developed medical standards.
• Unity in approaches when conducting examinations.
• Use of legal and economic methods.
• Monitoring of the KMP control system.
• Cost-effectiveness analysis, cost ratio with the optimal level of IMP.
• Studying the opinion of the population on issues of quality of medical care.

Levels of responsibility

The quality of medical care is the safety of medical activities and control. There are now 3 levels of control over the activities of medical institutions:

1. State.
2. Internal (in the medical facility itself).
3. Departmental.

Such a system was created not to duplicate checks, but to establish a clear framework of responsibility for the proper provision of medical services.

State control is aimed mainly at licensing the activities of medical organizations and conducting various inspections of compliance with human rights in the healthcare sector.

CMP in surgery

This issue is regulated by Order of the Russian Ministry of Health No. 922n. The specific procedure for providing medical care in the specialty of surgery applies to all medical institutions. It appears in the following forms:

1. Primary health care stage.
2. Specialized ambulance vehicle.

Medical care is provided on an outpatient basis (conditions that do not provide for treatment and observation by doctors around the clock), in a day hospital (treatment and observation only during the daytime), in inpatient settings (observation and treatment by medical staff around the clock).

During primary health care, activities are carried out for the purpose of prevention, diagnosis, treatment of surgical diseases, as well as medical rehabilitation, and the formation of a healthy lifestyle. It includes:

• Pre-medical primary health care.
• Primary medical care.
• Specialized primary health care.

Primary health care refers to a form of medical service delivery in which specialists provide treatment in a day hospital or on an outpatient basis. The duties of pre-medical primary health care are performed by a health worker, whose education must be at least secondary.

As for medical care, it is performed by general practitioners (local doctors) or a family doctor. If, upon examination by these specialists, indications for contacting a surgeon are revealed, then they give a referral to him.

In specialized primary health care, a surgeon examines the patient and prescribes treatment. If this is not enough, then he refers the patient to a medical organization that specializes in surgery.

An ambulance is needed when surgery is urgently required. It is staffed by paramedics and medical teams on the basis of Order of the Ministry of Health and Social Development No. 179 of November 1, 2004.

If there is a need to evacuate a patient during examination by ambulance specialists, they perform it in an urgent emergency manner. An ambulance team delivers a person with a life-threatening condition to a 24-hour anesthesiology, intensive care or surgery department. After the patient’s life-threatening factors have been eliminated, he is transferred to the surgical department for further medical care. If necessary, the surgeon involves other specialists to provide adequate treatment.

According to the profile, surgery should be based on accurate diagnosis, conscientious treatment using advanced technologies and productive, comfortable rehabilitation.

Planned care in surgery

Such medical care should be provided in cases of preventive measures. They are carried out only for simple diseases that do not require emergency assistance at the moment and do not pose a threat to the health and life of the patient.

To improve the quality of medical care, patients who have an atypical course of the disease, there is no positive result from treatment, or there is no final diagnosis, are referred to more high-tech medical organizations.

Also, patients who have specific medical indications are sent for rehabilitation to sanatorium-resort complexes.

Protecting patient rights

In the healthcare sector, unfortunately, there are still cases of imposition of paid services, unscrupulous doctors, financial losses or harm to health. Here, the law “On the Protection of the Rights of Consumers of Medical Services” No. 2300-1 takes the patient’s side. In Art. 31 of this law states that a period of 10 days is allotted for taking action on a claim, and the countdown begins from the date the complaint is received. In Art. 16 states that provisions of the contract that violate the rights of the patient are declared invalid.

Quality of medical care is the adequate provision of conscientious, satisfying medical services to the population. The patient has the right to:

• Receiving high-quality medical care in full and within the agreed time frame.
• Familiarization with complete information about the contractor and upcoming services.
• Providing him with comprehensive information that affects the quality of medical services provided.

It is important to note that it makes no difference on what basis (paid or free) the services are provided. Protection of consumer rights implies high-quality and complete service. The state monitors the quality of medical care.

Patient's rights in case of dishonest provision of medical services

In case of incompetent performance of services that do not comply with the concluded contract or government regulations, the consumer has the right to demand a reduction in the cost of treatment, eliminate existing deficiencies through additional treatment, reimburse costs, terminate the contract with coverage of losses, and also receive services provided again.

A person who received medical treatment in violation of the law can write an appeal to Roszdravnadzor and Rospotrebnadzor. These bodies are responsible for compliance with quality criteria for medical care. They are obliged to conduct an inspection at the medical institution about which the complaint was received.

Access to health care is a multidimensional concept that involves a balance of many factors within the strict practical constraints caused by the characteristics of a country's resources and capabilities. These factors include personnel, financing, transportation facilities, freedom of choice, public education, quality and distribution of technical resources. The balance of these elements, which maximize the quantity and quality of assistance actually received by the population, determines the nature and degree of its availability.

In the modern concept, accessibility of medical care means unimpeded access to all services in the health care system, regardless of geographical, economic, social, cultural, organizational or language barriers, which must be ensured and conditioned by a balance between the capabilities of the state and the country’s medical resources, including the availability and level of qualifications of medical personnel; adequate financing of the industry; transport accessibility, the ability to freely choose a doctor and medical organization, as well as the quality of medical care.

General criteria for the quality of medical care are the correct implementation of medical technologies, reducing the risk to the patient’s condition, optimal use of resources and satisfaction of medical care consumers.

The Law under comment provides guarantees to citizens for the provision of affordable and high-quality medical care. Some of the first guarantees outlined in the commented article are:

Organization of medical care based on the principle of proximity to the place of residence, place of work or training;

Ensuring the availability of the required number of medical workers and their level of qualifications;

Providing the opportunity to choose a medical organization and doctor.

According to Art. 21 of the Law, when providing medical care to a citizen within the framework of the program of state guarantees of free medical care to citizens, he has the right to choose a medical organization in the manner approved by the authorized federal executive body, and to choose a doctor, taking into account the doctor’s consent. Features of the choice of a medical organization by citizens living in closed administrative-territorial entities, in territories with physical, chemical and biological factors hazardous to human health, included in the corresponding list, as well as by employees of organizations included in the list of organizations of certain industries with particularly hazardous working conditions , are established by the Government of the Russian Federation.

To receive primary health care, a citizen chooses a medical organization, including on a territorial-precinct basis, no more than once a year (except in cases of a change in the citizen’s place of residence or place of stay). In the selected medical organization, a citizen makes a choice no more than once a year (except in cases of replacement of the medical organization) of a general practitioner, local physician, pediatrician, local pediatrician, general practitioner (family doctor) or paramedic by submitting an application personally or through your representative addressed to the head of the medical organization.

When choosing a doctor and a medical organization, a citizen has the right to receive information in a form accessible to him, including information posted on the Internet, about the medical organization, about the medical activities it carries out and about doctors, about the level of their education and qualifications.

To resolve the personnel issue in the field of health care, a strategy has been developed and is being implemented, which is aimed primarily at the correct distribution of personnel and eliminating imbalances in staffing, and eliminating imbalances. Thus, at present, large regional and regional hospitals, university and academic clinics do not experience a shortage of personnel, and in primary care, which ensures maximum access to medical care for citizens, there are not always enough medical workers. Another disproportion is observed in the distribution of doctors by specialty, where in some medical specialties the shortage of personnel is almost half, while in others there is a surplus.

Additional measures of social support for medical workers working in rural areas also contribute to the solution of personnel issues (see, for example, Decree of the Government of the Russian Federation of December 30, 2014 N 1607 “On monthly cash payments for housing and utilities to medical and pharmaceutical workers, living and working in rural settlements, workers’ settlements (urban-type settlements), employed in positions in federal government institutions,” letter of the Ministry of Finance of Russia dated October 30, 2015 N 02-01-09/62781 “On the possibility of providing subsidies for the implementation of monetary payments for living quarters, heating and lighting to medical and pharmaceutical workers of institutions living and working under an employment contract in rural settlements, workers' settlements (urban-type settlements), who are on staff at the main place of work in the institution."

Other personnel policy measures are also being taken - to increase the average salary of doctors and improve working conditions, to optimize the number of medical workers, etc.

Ensuring the availability and quality of medical care is also facilitated by the application of procedures for the provision of medical care and standards of medical care.

In accordance with Part 1 of Art. 37 of the commented Law, medical care is organized and provided in accordance with the procedures for the provision of medical care, mandatory for implementation on the territory of the Russian Federation by all medical organizations, as well as on the basis of standards of medical care. In accordance with Part 2 of this article, the procedures for providing medical care and standards of medical care are approved by the authorized federal executive body - the Ministry of Health of Russia.

As an example, let us point out the following acts:

The procedure for providing medical care to minors, including during the period of training and education in educational organizations (approved by Order of the Ministry of Health of Russia dated November 5, 2013 N 822n);

The procedure for providing emergency, including specialized emergency medical care (approved by Order of the Ministry of Health of Russia dated June 20, 2013 N 388n);

The procedure for organizing medical rehabilitation (approved by Order of the Ministry of Health of Russia dated December 29, 2012 N 1705n);

The procedure for providing medical care to children in the field of “neurology” (approved by Order of the Ministry of Health of Russia dated December 14, 2012 N 1047n);

The procedure for providing medical care to patients with tuberculosis (approved by Order of the Ministry of Health of Russia dated November 15, 2012 N 932n);

Order of the Ministry of Health of Russia dated December 20, 2012 N 1273n “On approval of the standard of primary health care for recurrent miscarriage” (ICD-10: O26.2);

Order of the Ministry of Health of Russia dated December 24, 2012 N 1503n “On approval of the standard of primary health care for arthrosis of the wrist joint and small joints of the hand and foot” (ICD: M05.8, M18, M19, M20);

Order of the Ministry of Health of Russia dated December 24, 2012 N 1479n “On approval of the standard of primary health care for impetigo” (ICD-10: L01.0), etc. (see the commentary to Article 37 of the Law for more details).

Accessibility and quality of medical care are ensured by the provision of a guaranteed volume of medical care by a medical organization in accordance with the program of state guarantees of free provision of medical care to citizens.

Thus, by Decree of the Government of the Russian Federation of December 19, 2015 N 1382, the Program of State Guarantees for the provision of free medical care to citizens for 2016 was approved, which establishes a list of types, forms and conditions of medical care, the provision of which is free of charge, a list of diseases and conditions, and the provision of medical care for which it is provided free of charge, categories of citizens for whom medical care is provided free of charge, average standards for the volume of medical care, average standards for financial costs per unit of volume of medical care, average per capita financing standards, the procedure and structure for setting tariffs for medical care and methods of payment, and also requirements for territorial programs of state guarantees of free provision of medical care to citizens in terms of determining the procedure and conditions for the provision of medical care, criteria for the availability and quality of medical care.

The program is formed taking into account the procedures for providing medical care and on the basis of standards of medical care, as well as taking into account the characteristics of the gender and age composition of the population, the level and structure of morbidity of the population of the Russian Federation, based on medical statistics.

State authorities of the constituent entities of the Russian Federation, in accordance with the Program, develop and approve territorial programs of state guarantees of free medical care to citizens for 2016, including territorial programs of compulsory health insurance established in accordance with the legislation of the Russian Federation on compulsory health insurance.

The quality and accessibility of medical care is ensured by compliance with the requirements established by the legislation of the Russian Federation for the location of medical organizations of the state health care system and the municipal health care system and other infrastructure facilities in the field of health care based on the needs of the population, transport accessibility of medical organizations for all groups of the population, including disabled people and other groups population with limited mobility, as well as the possibility of unhindered and free use by a medical worker of communication means or vehicles to transport a patient to the nearest medical organization in cases that threaten his life and health (see Order of the Ministry of Health of Russia dated February 27, 2016 N 132n “ On the Requirements for the placement of medical organizations of the state healthcare system and the municipal healthcare system based on the needs of the population,” Resolution of the Chief State Sanitary Doctor of the Russian Federation dated May 18, 2010 N 58 “On approval of SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations carrying out medical activities").

Availability of medical care is also ensured by the opportunity provided by law for a medical worker to freely and freely use communication means or vehicles to transport a patient to the nearest medical facility in cases that threaten his life and health. This right of medical workers often allows them to save the patient’s life. Fast and timely transportation to a medical facility is sometimes the only way to save a person, since his life depends on how quickly he is delivered to a medical facility and how quickly effective treatment can begin, and delay can cause irreparable harm. To exercise this right, vehicles and communications equipment belonging to enterprises, organizations, as well as individuals can be used.

Accessibility and quality of medical care are also ensured by equipping medical organizations with equipment to provide medical care, taking into account the special needs of people with disabilities and other groups of the population with limited health capabilities. The procedure for ensuring accessibility for disabled people to infrastructure facilities of the state, municipal and private healthcare systems and services provided in the field of health care, as well as providing them with the necessary assistance, was approved by Order of the Ministry of Health of November 12, 2015 N 802n.

The procedure and timing for the development by federal executive authorities, executive authorities of constituent entities of the Russian Federation, and local self-government bodies of measures to increase the values ​​of accessibility indicators for people with disabilities of objects and services in established areas of activity are approved by Decree of the Government of the Russian Federation of June 17, 2015 N 599.

Yu.T. Sharabchiev, T. V. Dudina

Accessibility and quality of medical care: components of success

Republican Scientific and Practical Center of Medical Technologies, Informatization, Management and Health Economics of the Ministry of Health of the Republic of Belarus, Minsk

The quality of medical care (QMC) is usually understood as a set of characteristics of medical care, reflecting its ability to meet the needs of patients, taking into account health care standards that correspond to the modern level of medical science, and the availability of medical care

This is a real opportunity for the population to receive the necessary medical care, regardless of social status, level of well-being and place of residence. In other words, quality medical care is timely medical care provided by qualified medical professionals and appropriate

requirements of regulatory legal acts, standards of medical care (protocols for patient management), contract terms or generally required requirements.

The main criteria for the IMC are usually considered to include the following characteristics:

1. Access to health care is free access to health services regardless of geographic, economic, social, cultural, organizational or language barriers.

The availability of medical care, declared in the constitutions of various countries, is regulated by national legal acts (NLA), which determine the procedure and volumes of free medical care, and is determined by a number of objective factors: the balance of the required volumes of medical care to the population with the capabilities of the state, the availability and level of qualifications of medical personnel, the availability in specific territories of the necessary medical technologies, the patient’s ability to freely choose the attending physician and medical organization, available transport capabilities that ensure timely receipt of medical

assistance, the level of public education on the problems of maintaining and promoting health, disease prevention.

Thus, the availability of medical care is the most important condition for providing medical care to the population in all countries of the world, reflecting both the economic capabilities of the state as a whole and the capabilities of a particular person. Nowhere is universal, equal and unrestricted access to all types of health services provided. It is believed that the way out of this situation is to reduce spending on ineffective types of medical interventions and concentrate efforts on providing citizens with equal access to the most effective medical services. This approach to equitable use of limited resources is called rationing and is practiced to varying degrees throughout the world. In poor countries, rationing is open and widespread, affecting almost all types of medical care; in economically rich countries, it is usually limited to expensive types of care or certain groups of citizens. In addition, in many states there is hidden rationing: queues that make it impossible to receive treatment in

reasonable deadlines, bureaucratic obstacles, exclusion of certain types of treatment from the list of free services, etc.

The readiness of society to increase the availability of medical care largely depends on the economic state of the country. But no country can spend more than 15% of GDP on the health of citizens, since these expenses will negatively affect the prices of manufactured goods, which may lose competitiveness. Therefore, recognizing the limitations of resources used to provide health care is fundamental to understanding the capabilities of medicine in society. It is important that rationing in the distribution of funds in the medical care system is effective, fair, professional and guarantees the possibility of obtaining high-quality medical care.

The mechanism that largely realizes the right to access to medical care is its standardization. Medical standards (protocols for patient management) are drawn up with an understanding of the limited means and features of providing care in various treatment and preventive organizations, therefore they contain the minimum level of necessary care. Sometimes it comes in

in conflict with the goal of providing technologically “state-of-the-art” care. According to V.V. Vlasov, accessibility of medical care can be realized by dividing requirements into minimal (mandatory) and requirements for optimal care, performed as needed (medical indications) and including expensive types of care. However, the second way, which enshrines expensive high-tech types of medical care in recommendations (standards), reduces its accessibility.

2. Adequacy. According to WHO experts, the adequacy of medical care is an indicator of the compliance of medical care technology with the needs and expectations of the population within the framework of a quality of life acceptable to the patient. According to a number of authors, adequacy includes the characteristics of accessibility and timeliness of medical care, which is understood as the ability of the consumer to receive the help he needs at the right time, in a place convenient for him, in sufficient volume and at an acceptable cost.

3. Continuity of medical care is the coordination of activities in the process of providing medical care to a patient at different times, different

our specialists and medical institutions. Continuity in the provision of medical care is largely ensured by standard requirements for medical documentation, technical equipment, process and personnel. Such coordination of the activities of health workers guarantees the stability of the treatment process and its results.

4. Efficiency and effectiveness - compliance of the actual medical care provided with the optimal result for specific conditions. Effective healthcare must provide optimal (with available resources) rather than maximum medical care, i.e., meet quality standards and ethical standards. According to the WHO definition, optimal health care is the proper implementation (according to standards) of all activities that are safe and acceptable for the money spent in a given health care system.

5. Patient-centeredness and patient satisfaction means the patient’s participation in decision-making in the provision of medical care and satisfaction with its results. This criterion reflects the rights of patients not only to quality medical care,

but also to the attentive and sensitive attitude of medical staff and includes the need for informed consent to medical intervention and respect for other rights of patients.

6. Safety of the treatment process is a criterion for guaranteeing safety for the life and health of the patient and the absence of harmful effects on the patient and the doctor in a particular medical institution, taking into account sanitary and epidemiological safety.

The safety and effectiveness of treatment for a particular patient largely depends on the completeness of the information available to the attending physician. Therefore, the safety of the treatment process, like other criteria, depends on the standardization of the treatment process and the training of the doctor. For example, in the United States, the training program for doctors, nurses and pharmacists includes training on the prevention of medical errors, a focus on providing quality medical care, and testing of healthcare professionals to determine their level of professionalism.

7. Timeliness of medical care: provision of medical care as needed, i.e. for medical reasons, quickly and without a queue.

The timeliness of care specifies and complements the criterion of its availability and is largely ensured by highly effective diagnostic procedures that allow timely initiation of treatment, a high level of training of doctors, standardization of the process of care and the establishment of requirements for medical documentation.

8. Absence (minimization) of medical errors that complicate recovery or increase the risk of progression of the patient’s existing disease, as well as increasing the risk of a new one. This component of quality medical care directly depends on the level of training of the doctor, the use of modern diagnostic and treatment technologies, as well as the establishment of qualification criteria at a specific workplace in the form of instructions, licenses, accreditations and ensuring sanitary, hygienic and metrological requirements.

9. Scientific and technical level. The most important component of the quality of medical care is the scientific and technical level of the applied methods of treatment, diagnosis and prevention, which allows us to assess the degree of completeness of care, taking into account modern advances in the field of medical

knowledge and technology. This characteristic of the ILC is sometimes included in the adequacy criterion.

Despite the right to affordable and high-quality medical care enshrined in the constitutions of many countries, the mechanisms for implementing this right vary from country to country, which largely depends on the type of healthcare system in place. In most countries, the main mechanisms ensuring accessibility and appropriate quality of medical care are the regulatory framework of the industry, which regulates the provision, management and control of medical care; standardization of the industry, carried out through regulatory and technical documents, and an examination system.

It is obvious that effective management of the quality of medical care is impossible without the creation of a regulatory framework regulating medical care at all levels of its provision. The regulatory framework of the industry is a system of interconnected legal acts from the law to the regulatory and technical document, mandatory for execution by all healthcare institutions, regardless of the form of ownership and regulating the legal basis for the provision of medical care, its quality, accessibility and control.

la. In each country, the regulatory framework of the industry is formed taking into account the national traditions of providing medical care.

Industry standardization. An analysis of foreign experience indicates the effectiveness of using medical standards in the field of medical services as a normative provision of quality guarantees and the main resource-saving tool that ensures the quality of medical care and the protection of patients' rights. Standards act as the most important science-based mechanism for making decisions about the general availability or restriction of availability of certain medical interventions. Over the past 10-15 years, economically developed countries have created the appropriate industry-specific regulatory framework and organizational structures to ensure the activities of healthcare institutions and medical workers within the framework of professional standards and evidence-based medicine.

An approach to ensuring and assessing the quality of medical care based on A. Donabedian’s triad has received worldwide recognition:

1) resources (or structure), including assessment of the standards of the resource base (personnel, equipment and medical equipment; material

but technical conditions for the stay of patients and the work of medical personnel);

2) process (or technologies), including standards for treatment, diagnostic, and prevention technologies;

3) results (or outcomes), including standards for the results of treatment, prevention, diagnosis, rehabilitation, training, etc.

Ultimately, systemic standardization in the healthcare sector is aimed at creating and improving regulatory regulation of the industry, ensuring accessibility and guaranteeing high quality medical care in the following main areas of standardization:

Medical technologies;

Sanitary and hygienic technologies;

Educational standards;

Organizational and management technologies;

Information Technology;

Medicine circulation technologies;

Technologies regulating issues of metrology and medical equipment.

The basis for creating a system for providing, assessing and monitoring the quality of medical care in all countries is the standardization of the organization of treatment and diagnostic

sky process. The creation and implementation in each health care facility of a system that ensures the appropriate level of medical services includes the following main stages: implementation of standards for the provision of medical care; licensing of medical activities; certification of medical services; licensing and accreditation of medical organizations; certification and certification of specialists; creation of a material and technical base that allows meeting the standards of medical care.

The development of continuously updated standards in the field of medicine throughout the world is carried out on the basis of the cost/effectiveness balance, based on the real situation, therefore clinical and economic research is the most important component of a modern medical care quality management system, determining trends in the development of the medical services market and allowing for optimization of planning resource provision for healthcare.

The system of clinical and economic standards currently in force in a number of countries includes a methodology for a comprehensive assessment of ICM based on the criteria of minimizing errors and optimal use of resources. In other words-

We mean that medical care of appropriate quality is provided by a qualified doctor in accordance with territorial standards of medical care and is expressed in the absence of medical errors.

Thus, the standard of medical care is a normative document that establishes requirements for the process of providing medical care for a specific type of pathology (nosological form), taking into account modern ideas about the necessary methods of diagnosis, prevention, treatment, rehabilitation and the capabilities of a specific medical care system, ensuring its proper quality .

Medical technologies (MT), along with standards, play an important role in the system for increasing medical medical care, since standards are updated when new MT are improved and introduced into practice. Since MT requires assessment and registration, each country has its own technologies and organizations that ensure their implementation in practice. International organizations for health technology assessment include ANTA - the International Network of Agencies for Health Technology Assessment and NTA1 - a public organization for health technology assessment.

In Russia, the assessment of MT and standards is carried out by the interregional organization “Society of Pharmacoeconomic Research” and the Society of Evidence-Based Medicine Specialists, Technical Committee 466 on Medical Technologies under the Federal Agency for Technical Regulation and Metrology, the Ethics Committee, the Pharmaceutical Committee and other organizations.

Medical technologies in the Russian Federation are registered by the Federal Service for Surveillance in Healthcare and are divided into:

Registered in the State Register of New Medical Technologies of the Ministry of Health of the Russian Federation;

Approved by letters of the Ministry of Health of the Russian Federation;

Approved by orders of the Ministry of Health of the Russian Federation;

Approved by current decisions of congresses of medical specialists of the Ministry of Health of the Russian Federation;

Registered as inventions;

Not registered.

Systematization, assessment and registration of MT create the prerequisites for the unification of treatment standards. In some countries, in addition to treatment standards, medical-economic standards, clinical guidelines, and

management, diagnostic and treatment protocols.

In Belarus, standardized medical technologies began to be used relatively recently and only in certain areas. So far, there is no unified concept for the development of standardization in the industry, a program of work on standardization of healthcare has not been approved, the organizational structure of the service has not been developed, the head and base organizations for standardization in healthcare have not been identified, and the governing body organizing work on standardization in the industry has not been identified. There are significant gaps in the regulatory framework for standardization; there is no system of information support for these processes. Due to the lack of system-forming regulatory documents regulating the organization of standardization work, the approved regulatory documents on the standardization of medical technologies are not “built into” real practice. The current diagnostic and treatment protocols in our republic are approved by orders of the Ministry of Health of the Republic of Belarus, and not by the Resolutions of the Ministry of Health of the Republic of Belarus, and are not published properly, therefore they are inaccessible and do not have the proper legal force.

In addition, there is a certain legal conflict in the understanding of the mandatory use of treatment standards. From the point of view of the law “On technical regulation and standardization”, standards are used voluntarily, but from the point of view of the legal acts approved by the order of the Ministry of Health, their implementation is mandatory. In the Russian Federation, to eliminate such a conflict, an amendment was adopted to the Federal Law “On Technical Regulation”, which noted that this law does not regulate relations related to the prevention and provision of medical care.

Expertise and quality control of medical care. Expertise is a prerequisite and the main mechanism for ensuring and controlling the quality of MP. The examination of ILC is carried out at various levels of the healthcare system and is regulated by special regulations. Any examination is aimed at eliminating or identifying medical errors and defects in the provision of medical care.

A defect in the provision of medical care is understood as the improper implementation of diagnosis, treatment of a patient, or organization of the process of providing medical care, which led or could lead to an unfavorable outcome of medical intervention.

A close and, in fact, identical concept in relation to defects

provision of MP is iatrogenic. Iatrogenesis (iatrogenic pathology) is a defect in the provision of medical care, expressed in the form of a new disease or pathological process that arose as a result of both legal and illegal implementation of preventive, diagnostic, resuscitation, treatment and rehabilitation medical measures (manipulations).

There are the following defects in medical care that are a direct consequence of medical intervention:

1) intentional iatrogenics (intentional defect) - defects in the provision of medical care associated with an intentional crime;

2) careless iatrogenic (careless defect) - defects in the provision of medical care containing signs of a careless crime;

3) erroneous iatrogenies (medical error) - defects in the provision of medical care associated with a conscientious error of a medical worker, which do not contain signs of intent or negligence;

4) accidental iatrogenics (accident) - defects in the provision of medical care associated with an unforeseen combination of circumstances during the lawful actions of medical workers.

In medical and legal

The Russian literature contains more than 60 definitions of medical error, while this concept is absent in the legislative acts of many countries. In its integrated form, a medical error is harm to the health or life of a patient caused by an erroneous action or inaction of a medical worker, characterized by his honest mistake in the proper attitude to professional duties and the absence of signs of intent, negligence, negligence or imprudence. In other words, a medical error is understood as a conscientious error of a doctor, based on the imperfection of medical science and its methods, or the result of an atypical course of the disease or insufficient training of the doctor, unless elements of negligence, inattention or medical ignorance are detected.

There are subjective and objective causes of medical errors. Subjective reasons include underestimation or overestimation of clinical, laboratory and anamnestic data, consultants’ opinions, insufficient qualifications of the doctor, incomplete and (or) late examination of the patient, underestimation of the severity of his

condition. Objective reasons include the short duration of the patient’s stay in the clinic or late hospitalization, the severity of the patient’s condition, the complexity of diagnosis due to the atypical course of the disease and insufficient information about the pathological process, lack of material resources and medicines.

Defects in the quality of medical care. Analysis of medical device defects is mandatory both from the point of view of investigating their causes and in connection with the need to introduce professional liability insurance for medical workers into practice.

According to international statistics, the most significant causes of defects in the work of doctors include insufficient qualifications of medical workers - 24.7%, inadequate examination of patients - 14.7%, inattention to the patient - 14.1%, deficiencies in the organization of the treatment process - 13. 8%, underestimation of the severity of the patient’s condition - 2.6%. According to international judicial practice, defects in the organization of medical care account for at least 20% of all defects in medical care. According to the American Medical Association, more than 200,000 people die each year in the United States due to the fault of medical workers.

Human . Approximately the same number of people die from inappropriate prescriptions or side effects of medications. From 3 to 5% of hospital admissions are caused by side effects of medications, which is tens of times more than due to surgical errors. In Russia, according to experts, every third diagnosis is made incorrectly.

The examination of clinical medical care is carried out by identifying defects in its provision, to prove which, first of all, the licensing activities of the institution and compliance with the standards of medical care are studied. The main methods of examination are studying the opinions of fellow experts and comparing the medical activities of an institution with world practice using quality indicators for assessing the correctness of the actions of medical personnel.

N.I. Vishnyakov et al. propose to distinguish three main parts of the system of examination and quality control of medical care:

On the part of the manufacturer of medical services (internal quality control);

On the part of the consumer of medical services (consumer quality control);

On the part of organizations independent of consumers and

manufacturers of medical services (external quality control).

Departmental examination and control of the ILC is carried out as planned by order of higher officials. Departmental control of the quality and effectiveness of medical care is the main type of control, closest to the providers of medical services. Its results are compared with the data of non-departmental examination. Indicators of the quality and efficiency of medical care can be used for differentiated remuneration of health workers.

To improve the system of supervision and control over compliance with the requirements of regulatory documents on ILC, Russian experts recommend creating a Center for Standardization in Healthcare. At the same time, it is unlawful to assign control functions to the body implementing standards. There is an opinion that the functions of licensing, accreditation and certification as components of a unified standardization system in healthcare should be removed from the departmental system. Currently, these functions are dispersed among various structures performing licensing and accreditation activities.

Non-departmental examination and control of the IMP is carried out on the basis of an assessment of the resource and personnel capabilities of health care institutions, the technologies used in the institution, as well as indicators of the volume and results of activities. Activities to examine the quality and volume of medical care are carried out on the initiative of any participant in civil legal relations (licensing and accreditation commissions, medical insurance organizations, territorial compulsory health insurance funds, insurers, professional medical associations, societies (associations) for the protection of consumer rights, etc.) .

The main task of subjects of non-departmental quality control of medical care is the organization of medical and medical-economic examination in order to ensure the right of citizens to receive medical care of adequate quality and verify the effectiveness of the use of health care resources, as well as financial resources of compulsory health insurance (CHI) and social insurance.

In addition to these types of ILC examination, many countries effectively operate a preventive control system, which is an additional mechanism for ensuring

ensuring proper quality of medical care. As a rule, the preventive control system is well developed in countries with compulsory medical insurance. In the Russian Federation, for example, preventive control is carried out by the licensing and accreditation commission before licensing and accreditation of a medical institution or individual. The purpose of preventive control is to assess the ability of a medical institution or individual to provide the declared types of medical care, as well as the compliance of their activities with established standards.

To date, the ILC criteria used to distinguish between appropriate and inappropriate medical care have been thoroughly developed only in forensic medicine and in the field of health insurance. Taking this into account, there is an urgent need to create unified approaches to assessing IMC, based on generally accepted principles, criteria and indicators, which should be contained in professional standards and enshrined in law.

Common to all criteria for assessing medical care in all countries is minimizing errors and optimal use of financial resources with mandatory standardization of medical care delivery processes.

The most objective (and direct) criterion for CMP remains the patient’s condition (quality of life).

In an integral assessment of medical care, it is customary to consistently consider the following characteristics: the effectiveness of the treatment process, the effectiveness of medical care, the technical and technological competence of specialists, the safety of patients and medical personnel in the process of treatment, the availability of medical care and the principles of its provision. The interpersonal relationship between the doctor and the patient, the continuity of the treatment process, and the patient’s satisfaction with the ongoing treatment and preventive measures are also subject to assessment.

ILC assessment is carried out at different levels: country, region, individual medical institutions. Accordingly, the criteria for its assessment at each level will differ. At the national level of health care management, quality of care measures include demographic indicators, morbidity data, and other health care facility records. In the Republic of Belarus, for example, to assess the IMP, you can use the criteria laid down in the territorial model of final results.

Main indicators of the quality of medical care. According to the terminology adopted in the Russian Federation, indicators of the quality of medical care are numerical indicators used to evaluate medical care, indirectly reflecting its main components: resources (structure), processes and results. These quantitative indicators, usually expressed as percentages, are used to evaluate the activities of health care facilities, forecast the development of practical medicine, as well as differentiated wages depending on the quality of work. The ILC is usually considered from the standpoint of:

The quality of the material and technical base of health care facilities and medical personnel;

Availability of medical technologies with proven effectiveness;

Availability of approved technologies for performing medical services;

Availability of optimized organizational technologies;

Availability of indicators for assessing the health of patients and their assessment during the treatment process;

Analysis of the compliance of the obtained clinical results and the costs incurred.

Threshold (target) values ​​of the ILC indicator are the range of values ​​​​set as target or acceptable (when assessing the frequency

such negative phenomena as complications, repeated hospitalizations, mortality, etc.) according to control points of the treatment process. Sources for establishing threshold values ​​for quality indicators include clinical guidelines, systematic reviews, best practice results, and expert opinions. A quality indicator can have a target value and an actual value achieved. The ratio of the actual value of the quality indicator to the target value, expressed as a percentage, is called the goal achievement index.

Resource indicators (structures) - quantitative indicators used to characterize individuals and organizations providing medical services. They can be used at any level of the healthcare system (industry, territory, individual healthcare facility) and characterize the following areas:

Conditions for providing medical care;

Adequacy of financing and use of financial resources;

Technical equipment and efficiency of equipment use;

Number and qualifications of personnel;

Other resource components.

Indicators of medical processes are used to assess the

correctness of management (treatment) of patients in certain clinical situations (during prevention, diagnosis, treatment and rehabilitation). The number of quality indicators selected for monitoring is determined by the complexity of the tasks. Therefore, in developed countries, the management of patients with diseases that have the greatest weight in the structure of mortality is usually monitored.

Results indicators. Outcome assessment is the determination of the patient's health status after treatment and comparison of the results with reference standards established on the basis of scientific experiments and clinical assessments. These are the main characteristics of medical care when expected results are compared with those actually achieved. The most commonly used outcome indicators are hospital readmission and in-hospital mortality.

In the European Union countries, an ILC assessment system open to the public has been in place for several years. The annually compiled rating of medical institutions, ranked by points, makes it possible to judge the degree of openness of national health care systems for consumers of its services. In the “European Health Consumer Index 2007”, Austria took first place, which

1000 possible points scored 806. According to the European Healthcare Consumer Index 2007, the openness of healthcare systems is determined by criteria that reflect the extent to which a consumer can exercise his rights. For example, in Denmark, clinics are assigned categories of various stars, like hotels, not only for service and comfort, but also for reducing mortality and medical errors. In terms of the quality of treatment, Belgium and Sweden were ahead, and the quality of treatment was assessed solely in accordance with the interests of the patient - in terms of survival after a serious illness. The criteria for the quality of treatment also include infant mortality, the number of cases of nosocomial infections, etc. In addition, in the European Union there is a public organization called the Initiative Group of Medical Services Consumers, which evaluates the activities of the system from the point of view of patients.

The healthcare system in our country using the above criteria and indicators would receive a low rating. This is primarily due to the fact that, despite the rights of patients declared in the basic laws in the healthcare sector of the Republic of Belarus, the mechanism for their

protection and the role of public organizations. In addition, there is no publicly accessible qualification register of doctors and clinics in the republic. A patient receiving medical care in the public health care system does not have a real opportunity to obtain pre-trial compensation in the event of a medical error. There is a procedure that limits the patient’s ability to contact certain highly specialized specialists in the clinic, bypassing the therapist. This is convenient from the point of view of saving money for the clinic, but makes the patient dependent on the competence of the therapist. Queues at clinics, the lack of a system of non-departmental examination of clinical medical care and much more, for which the domestic healthcare system can be reproached, once again emphasize the importance of creating a system of adequate quality of medical care in the Republic of Belarus.

Methodology of quality management in healthcare. Quality management is not just an assessment of the final result, but the creation of a special technological process that ensures compliance with certain requirements and standards. Deviation from technological conditions (or what is called defects in the provision of medical services)

Qing aid) depends not only on the performers, but also on the system in which they work.

Each country uses its own methodology for quality management in healthcare, legitimized in national and international regulations. In the Russian Federation, for example, the creation of a quality control system in healthcare and the definition of its legal basis is regulated by the Law on Health Insurance (1993), orders of the Ministry of Health of the Russian Federation and the Federal Compulsory Medical Insurance Fund on departmental and non-departmental quality control (1996), and the Government Decree on the Program of State Guarantees of Free Medical Care ( 1998), Orders of the Ministry of Health of the Russian Federation “On the implementation of Patient Management Protocols” (1999), “On the introduction of the Institute of Quality Commissioners” (2001) and other documents.

International experience in creating a medical care quality management system includes the following main organizational tasks:

Interdepartmental interaction of management structures, medical and preventive institutions and institutions of the health insurance system, medical associations, public organizations and patients;

Development of a unified methodology for intra- and extradepartmental testing

principles of the quality of medical care, as well as indicators (indicators) of the quality of medical care and methods for assessing these indicators;

Development and implementation of a system for monitoring the quality of medical care, aimed at collecting information with subsequent analysis and making management decisions to improve long-term planning;

Development of a system of standardization, licensing, certification, accreditation in healthcare;

Development and implementation of a motivation system and economic mechanisms for stimulating medical workers depending on the amount of work done, the quality and results of the medical care provided.

Thus, the essence of the concept of quality management of medical care is to make management decisions based on the analysis of target indicators (or results) of activities, which have a multi-stage (hierarchical) structure and are formed according to the principle of a “tree of goals” for the institution as a whole, each management block (type activities), a single unit and are expressed in quantitative indicators.

A system of indicators is developed in each organization and

reflects its specificity and priorities. For this purpose, an optimal organizational structure is formed in the institution, best adapted to solving strategic problems and implementing functional strategies. A special place is occupied by the assessment of resource provision, therefore an important point in the field of improving quality and minimizing costs is the assessment of the so-called loss function. According to G. Taguchi, quality characteristics are costs and losses resulting from any deviation from the required quality. G. Taguchi defines losses as a function of the loss coefficient multiplied by the square of the difference between the required and received quality levels. In this case, quality losses increase quadratically as the obtained quality values ​​deviate from the required indicators. For example, a 2-fold loss in patient care time leads to a 4-fold increase in medical costs due to possible complications. The cost of preventing defects is 25% of the total cost of services, and the share of the cost of eliminating the consequences of defects reaches about 3/4 of the cost of services. In world practice, the upper and lower limits are taken as the reference target quality standard

tolerances for each indicator, located at a distance of ± 6 8 from the average value.

In modern conditions, the quality management system in healthcare is focused on the development and approval of standards (including patient management protocols), covering both the main activities and the work of supporting services, as well as the creation of a system of permitting and control mechanisms, the search for elimination and prevention measures defects.

It is believed that improving the quality of MP inevitably requires additional time, effort and resources. However, attracting additional resources does not at all guarantee an increase in the IMP. At the same time, the introduction of standards can lead to “leveling” of quality and minimizing costs. Improving the quality of medical care (at the first stage - correct diagnosis) helps to increase efficiency, reduce treatment time, reduce the frequency of re-hospitalizations and complications, which significantly reduces healthcare costs.

With the development of evidence-based medicine, it becomes obvious that many clinical and organizational aspects of medical care require revision of legislative and regulatory

mechanisms, including in our republic. First of all, a multi-level system for managing, assessing and monitoring the quality and examination of medical care is needed, linked to a system for monitoring resources spent on its provision, which can be a system of national accounts. It is important to create an institute for the standardization of medical care, carried out on the basis of clinical guidelines, patient management protocols, diagnostic and treatment standards that have the appropriate legal status.

The creation and replication of high-tech medical care centers across the regions of the republic undoubtedly helps improve the quality of medical care and form an opinion among the population and medical workers regarding what the level of medical care, including medical services, should be. However, we should not forget that in centers of high-tech types of medical care less than 1% of the volume of medical care and medical services is provided; and in a regular clinic, hospital, and even in a clinical hospital, the quality of medical care, to put it mildly, leaves much to be desired. There is no need to talk about medical services.

In this regard, it is advisable to form several exemplary healthcare organizations (clinics, hospitals, clinical hospitals), in which the issue of quality of medical care and medical service will be resolved with the required modern equipment and which will be staffed with well-paid, certified medical workers of high qualifications and professional culture .

It is extremely important for the creation of a system for the provision of high-quality medical care to be introduced in the republic of compulsory medical insurance (insurance of financial risks associated with the provision of medical care). Currently, Belarus remains one of the few countries in the world where there is no compulsory medical insurance system (among developed countries it is probably the only one). Meanwhile, the introduction of the compulsory medical insurance system is a natural and evolutionary process of healthcare development in all socially oriented countries, not only allowing to improve the quality of medical care through a system of independent examination, but also contributing to the influx of additional financial resources into healthcare, competition among medical organizations, and the formation of a medical market

services, reducing unit costs for providing medical care, introducing new medical technologies, standardizing healthcare and actually using treatment standards and protocols in practice.

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UDC 614.2+26.89

AVAILABILITY OF MEDICAL CARE AT THE STAGES OF ITS PROVISION

M.A. STEPCHUK1 T.M. PINCUS ^V. ABRAMOVA1 D.P. BOZHENKO2

In the article, the authors highlighted the issues of accessibility of medical care at the stages of its provision in Russia and the Belgorod region: they gave a definition of the concept of accessibility, factors influencing its provision, difficulties encountered and ways to solve them, differences in the levels of accessibility of medical care for the urban and rural population of the region.

Medical information and analytical center, Belgorod

Chernyanskaya central district hospital, Belgorod region

Key words: accessibility of medical care.

Ensuring the quality and accessibility of medical care is one of the most important and most difficult healthcare problems to solve. According to the World Health Organization (WHO), “a guarantee of the quality of medical care is the provision to each patient of that complex of diagnostic and therapeutic care that would lead to optimal results for the health of that patient in accordance with the level of medical science.”

Access to health care is free access to health services regardless of geographic, economic, social, cultural, organizational or language barriers. Ensuring universal access to effective health services of acceptable quality is considered by WHO as a mandatory requirement at the current stage of social development [Report on the state of health care in Europe. 2002 Copenhagen]. Thus, the availability of medical care is the most important condition for providing medical care to the population in all countries of the world, reflecting both the economic capabilities of the state as a whole and the capabilities of a particular person. Nowhere is universal, equal and unrestricted access to all types of health services provided. It is believed that the way out of this situation is to reduce spending on ineffective types of medical interventions and concentrate efforts on providing citizens with equal access to the most effective medical services. This approach to the rational use of limited resources is called rationing and is practiced to varying degrees throughout the world.

The state's readiness to increase the availability of medical care largely depends on the economic state of the country. But no country can spend more than 15% of GDP on the health of its citizens, since these expenses will negatively affect the cost of products and services produced, which may lose competitiveness. Countries around the world spend from 17 to 2% of GDP on healthcare, with an average of 8.7%. In the USA, healthcare costs are 13-16%, Switzerland - 11.6%, Germany

9.9-10.9%, France - 9-10.6%, Great Britain - 6.7% of GDP. The total expenditures of the federal budget, consolidated budgets of the constituent entities of the Russian Federation and compulsory health insurance funds for financing healthcare, in relation to the country's gross domestic product, have been declining in recent years (3.1% in 2002, 2.9% in 2003, 2.8% - in 2004), while according to WHO recommendations, healthcare costs should be at least 5% of GDP. Therefore, recognition of the limited resources used to provide medical care is fundamental to understanding the possibilities of medicine in society [Maleva T.M. 2007]. In connection with the implementation of the priority national project “Health” and the pilot project, healthcare financing increased and reached its peak in 2008 - 5.3% of GDP, and by 2010 it decreased to 3.3%

(325 billion rubles). When there is a shortage of funding, it is important that rationing in the distribution of funds in the medical care system is effective, fair, professional and guarantees the opportunity to receive quality medical care.

To a large extent, the mechanism that realizes the right to access to medical care is its standardization. Medical standards (protocols for patient management) are drawn up taking into account the limited funds and characteristics of providing care in various treatment and preventive organizations, therefore they contain the minimum level of necessary care. This sometimes conflicts with the goal of providing technologically “modern” care. Availability of medical care can be realized by dividing requirements into minimal (mandatory) and requirements for optimal care, performed for medical reasons and including expensive types of care [Vlasov V.V. 2007]. However, the second way, which establishes expensive high-tech types of medical care in the standards, reduces its accessibility.

In the Russian Federation, the accessibility of medical care is legally considered as one of the basic principles of protecting public health (Article 2 of the Fundamentals of the Legislation of the Russian Federation on protecting the health of citizens). At the same time, the accessibility of health care services is understood not just as the ability to go to a medical institution, but as the timely receipt of care that is adequate to the need and provides the best health outcomes, provided that the personal expenses of consumers for medical services should not be an unbearable burden on the family or personal budget and all the more reason to refuse treatment. The availability of medical care in the Russian Federation is determined by:

Balancing the volume of medical care needed by the population of the Russian Federation with the capabilities of the state, medical and financial resources of the country;

The ability for the patient to freely choose the attending physician and medical organization;

Availability and level of qualifications of medical personnel;

Availability of necessary medical technologies in the territories;

Available transport capabilities;

Organization of medical care at all stages of its provision (pre-medical care, medical, specialized);

The presence of mobile units to provide medical care in remote (inaccessible) settlements;

The cost of medical services;

The level of public education on the problems of maintaining and promoting health, disease prevention.

Based on this, the main strategic direction for increasing the accessibility and quality of medical care is to provide all the necessary conditions in order to meet the needs of the population of the Russian Federation for quality medical care at all stages - from outpatient care to specialized care. In this regard, the Russian government has identified the task of increasing the availability and quality of medical care for the entire population of the country, and it has been set as the main goal of the health policy [Concept for the development of healthcare in the Russian Federation until 2020 and the program of state guarantees for 2011].

In the Russian Federation, there are significant differences in the opportunities to receive medical care for different groups of the population. They are due to the very history of the formation of the Russian health care system (the presence, in addition to the network of publicly accessible state health care institutions, of parallel departmental health care systems), a reduction in state funding for health care, the decentralization of public finances and significant differences in the economic potential of different territories, growing inequality in the distribution of income between various social and territorial in groups. The beginning of Russia's recovery from the economic crisis is characterized by various levels of

economic development and health care financing opportunities in different regions, which requires further changes in government policy to ensure access to medical care.

Analysis of data from ongoing sociological studies shows differences: in the number of people seeking medical help; availability of free care and access to paid medical services for men and women; groups with different levels of education and income; for the population living in different regions and in different types of settlements [Ovcharova L.N. 2005; RSzdravnadzor. 2008]. In order to select priorities to level out existing inequalities, a more detailed analysis of the situation and the development of specific proposals for the healthcare modernization program for 2011-2012 are required.

Healthcare in the Belgorod region is no exception. As in other regions, there is an imbalance between the guaranteed volumes of medical care and the amount of financing and medical resources. The budget of the Belgorod region for 2010 provides for a total of 2,655.8 million rubles (5.8% of the regional budget) in the general line “Healthcare, physical education and sports”. In this regard, the territorial program of state guarantees of free medical care to the population of the region in 2010 had a funding deficit of 38.6%. Accordingly, the tariff agreement approved lower prices for medical services. This had a negative impact on the availability and quality of free medical care to the population, and first of all, primary health care, high-tech care for less protected segments of the population and residents of inaccessible settlements located far from the central district hospital, district, district hospitals and GP centers. The construction and major repairs of many health care facilities have not been completed, new medical equipment has not been purchased, and patients have not been adequately treated using effective, expensive medicines. As before, about 60% of funds were allocated to provide inpatient treatment.

The availability of medical care in the region depends on the patient’s ability to freely choose their attending physician and medical organization. In accordance with the Law “On Insurance of Citizens of the Russian Federation” of 1990 and dated November 28, 2010, residents are granted this right. Orders of the Ministry of Health and Social Development of the Russian Federation dated July 29, 2005 N 487 “On approval of the Procedure for organizing the provision of primary health care” and dated August 4, 2006 N 584 “On the procedure for organizing medical care for the population on a local basis” provided a tool to the heads of medical institutions for organizing the provision of primary health care service area, respecting the right of citizens to choose their attending physician and medical organization. The chief physician has the right to assign for medical care no more than 15% of patients from areas served by other local doctors (Order of the USSR Ministry of Health of 08/07/1987 No. 938 “On the free choice of a local doctor”) or other clinics. This right is widely used by residents of the region's cities. In populated areas of the region and most district centers where there is only one health care institution, this right is limited, but the opportunity to choose the attending physician remains. In addition, patients have the opportunity to turn to specialists in private medical organizations or private medical practitioners, the number of whom in the region increases annually, and exceeded 12% of the total number of doctors in the region, and dentists (dentists) - more than 50%. In state and municipal health care institutions, paid service rooms have been organized, where medical services can be obtained without waiting in line, at a time convenient for the patient and with increased comfort. However, not all groups of the population (pensioners, unemployed, students, etc.) can afford paid services. In addition, the price of medical services is increasing every year. For example, today on average you need to pay more than 800 rubles for an ultrasound examination, and two years ago - 260 rubles. For a visit to a doctor at a healthcare facility, no more than 150 rubles are transferred from compulsory medical insurance funds, and a visit to a private doctor costs at least 300 rubles. etc.

Access to medical care depends on the availability and level of qualifications of medical personnel. Medical personnel, being the most valuable and significant part of healthcare resources, ultimately ensure the results

activity and efficiency of the entire healthcare system. The region's healthcare sector employs 35,367 employees; the number of doctors in 2009 compared to 2005 increased by 3.9% and amounted to 5,514 people (2005 - 5,305). The number of paramedical workers increased by 1.9% and amounted to 16,796 people (2005 - 16,485). Accordingly, the supply of doctors increased by 1.1% and amounted to 35.5 per 10,000 population (2005 - 35.1, Russian Federation - 44.1). The provision of paramedical personnel increased by 0.6%, the figure was 109.8 (2005 - 109.1, Russian Federation - 94.3).

Analyzing the staffing of healthcare institutions in the region with doctors, it is necessary to note the low supply of doctors in rural areas, which was explained by the abolition of the state distribution of graduates and the social instability of medical workers. The lack of normal social and living conditions, and especially housing, made it very difficult to secure qualified specialists in rural areas. However, in recent years (2005-2010), as a result of the implementation of the priority national project “Health” and social benefits for doctors in rural areas provided by the regional government (provision of housing, allocation of free plots and interest-free loans for housing construction with partial payment for construction, etc.) , gave a positive result. The shortage of doctors in health care facilities in the region decreased by 25% and amounted to 30.2% (2005 - 55.2), including specialists providing outpatient medical care - 28.0%, inpatient medical care - 37.8%, emergency medical care assistance - 34.6%. In addition, about 19% of doctors and 11% of paramedical workers of retirement age work in the industry. The staff of paramedical workers is 100% staffed. Almost all rural areas in the region are staffed with doctors, and the part-time ratio of local service doctors in the region as a whole has decreased to 1.1, while (at the municipal level) among doctors of all specialties it is 1.3, and in individual (remote) ) areas -1.5-1.6. At the same time, the number of local therapists decreased by 72.5% and amounted to 425 people (2005 - 733), the provision of them was 3.4 per 10,000 population (2005 - 4.8). At the same time, the number of general (family) practice doctors (excluding those on maternity leave) increased 2.6 times and amounted to 246 (2005 - 96), and the number of them amounted to 1.6 (2005 -0 ,6), which significantly exceeds the average for the Russian Federation.

The share of doctors with specialist certificates increased from 91.3% in 2005 to 94.1% in 2009, and paramedical workers - from 85.9 to 89.9%, respectively. About 1,000 doctors and 3,000 workers with secondary medical and pharmaceutical education are certified annually to receive qualification categories. 48.6% of doctors (2005 - 53.2) and 59.2% of paramedical workers (2005 - 60.4) have a qualification category. More than 120 candidates and more than 20 doctors of medical sciences work in healthcare.

In order to provide the social sphere of the region with human resources in accordance with the needs and priorities of socio-economic development, the Belgorod Region Government Decree No. 357-pp dated October 23, 2010 approved the long-term target program “Formation and development of a regional personnel policy system” for 2011-2015. Among the program's activities in the healthcare industry is targeted contract training of applicants and interns from among the residents of the region, especially rural areas.

The region has a system of continuous professional education of medical personnel. Every year, based on applications from healthcare institutions, a plan for advanced training and certification of doctors and paramedical workers is formed and implemented at the expense of the regional budget, allowing 100% of specialists to be covered by training within 5 years.

More than 3,000 mid-level, junior and other medical personnel were trained annually at the Institute of Postgraduate Medical Education of Belgorod State National Research University (BelSU) and Stary Oskol Medical College. More than 1,000 doctors were trained on the basis of BelSU and on-site cycles. The share of doctors and paramedical workers who completed postgraduate training in 2010 was 18.6% and 19.4% of

the total number of specialists, respectively. In 2011, postgraduate training in general improvement and professional retraining courses is planned for 19.1% of doctors and 19.7% of paramedical workers. The strategic goal for the coming years is to further improve the qualifications of primary care doctors as part of the implementation of a priority national project. It is planned to introduce information technologies into the learning process, as well as to develop and implement a credit and savings system for additional postgraduate education.

Conclusion: Over the past five years, there has been a positive trend in increasing the staffing of primary health care in the region and improving the qualifications of medical workers, which has affected the dynamics of equalizing the availability of medical care in rural areas and cities. However, this problem continues to exist.

The availability of necessary medical technologies in healthcare facilities in the area affects the availability of medical care. Over the past 5 years, the material and technical base of medical institutions has been improved, more than 3 billion rubles have been allocated for the construction of healthcare facilities. In 2009 alone, 624.3 million rubles were spent on the construction, reconstruction and major repairs of 27 healthcare facilities. The construction of the cardiac surgery center of the regional clinical hospital of St. Joasaph has been completed, which provides the opportunity for a larger-scale provision of high-tech medical care to residents not only of the region, but also of other regions of the Russian Federation. Further creation and equipping of general medical practice (family medicine) centers located in rural areas was carried out. These measures only partially solved the problem. Currently, there are 412 buildings in the region that house medical institutions (hospitals, clinics, centers), of which 9.7% require major repairs and 9.2% require ongoing repairs; 7 facilities require completion of previously started construction. This is especially pronounced in rural areas. 18 buildings do not have a centralized water supply, there is no hot water supply in 130 buildings, and central heating in 50 buildings. Only 33 buildings (8%) have autonomous power supply. In addition, there are 565 buildings of medical and obstetric centers, of which 49% require major repairs. Accordingly, the use of modern medical technologies is hampered, not only due to the lack of funds for their acquisition, but also due to the lack of appropriate premises in a number of health care facilities for their placement.

In 2007-2008 As part of the implementation of the priority national project "Health", medical equipment was supplied to outpatient clinics in the region at the expense of federal funds, and at the expense of federal and regional budgets (as part of a pilot project) - to a small number of diagnostic and treatment devices and instruments for hospitals . However, the issue of equipping institutions with modern equipment remains unresolved. Currently, more than 17% of medical equipment has a service life of over 10 years and 100% wear, about 22% - from 6 to 10 years with more than 50% wear, and only 61% of equipment has been in use for no more than 5 years and has 30-40% wear. . In this regard, the capital-labor ratio of healthcare institutions in the region is only 449.9 rubles. for the number of doctors and equipment - 3,540.3 rubles. per 1 square meter of area. Because of this, the population’s access to modern methods of examination and treatment, especially the rural population, suffers.

Availability of medical care is affected by available transport capabilities. In the regional center, cities and most district centers, this issue has been resolved satisfactorily. However, during rush hours it becomes difficult to get to the clinic and travel prices rise (10 rubles one way), which deters part of the population from seeing a doctor in a timely manner. Transport options in rural areas are significantly worse. You can take a regular bus (flight to the regional center 1 in the morning and 1 in the evening) to the clinic of the Central District Hospital, but at this time buses arrive from all the large villages of the region, and a large queue forms at the clinic. Moreover, in these same morning hours there was a mass appeal from residents of the regional center itself. At best, you can get an appointment with a doctor, but take tests and undergo some

instrumental examinations (without appropriate preparation) will not be possible on this day. Many rural residents cannot come the next day due to the specifics of their way of life (seasonal agricultural work, feeding livestock, milking, etc.) and the high cost of travel. Buses to the regional center from inaccessible farms and villages run 1-2 times a week, even if they are located at a significant distance from clinics. It is even more difficult to go for a consultation to the regional center. Thus, a trip from the Rivne district takes more than 8 hours and the fare is over 600 rubles. On average in the region, the fare costs about 300 rubles and takes more than 4 hours, not counting the time of travel around the regional center. Thus, transportation options make it difficult to access medical care, especially for residents of rural settlements located far from clinics.

In addition, the availability of medical care is greatly influenced by the organization of medical care at all stages of its provision (pre-hospital, medical, specialized). In order to make medical care accessible to rural residents, a network of first aid stations, medical outpatient clinics, and general medical practice centers (departments) has been developed.

As we can see from the table, the restructuring of the region’s healthcare affected hospital institutions, and their number over 5 years decreased by 9.8%, the number of round-the-clock beds decreased by 12.8% and the provision of beds for the population decreased by 14.6%. Thus, part of the volume of inpatient care has been transferred to the outpatient clinic.

Rural healthcare developed according to the following scheme: in a number of district hospitals, inefficient beds were reduced or transferred to social protection, and nursing homes were organized on their basis. Thus, the local hospital was reorganized into a medical outpatient clinic and nursing home, or simply into a medical outpatient clinic. At the second stage, the medical outpatient clinic was reorganized into a center of general medical practice (family medicine) or a department of general medical practice of the Central District Hospital. A number of FAPs have also been reconstructed, equipped and reorganized into general medical practice centers. In this regard, the number of district hospitals decreased almost 2 times, the number of outpatient clinics decreased by 30%, and the number of first aid stations decreased by 3.6%, and the number of primary care centers and departments increased 2.9 times. In order to compensate for the reduced volumes of inpatient care, day hospitals have been established at outpatient clinics, general medical practice centers and the remaining district hospitals. Moreover, hospital-replacement types of medical care were in demand due to the fact that rural residents, having received treatment, could continue to do housework. They are also in demand in regional centers and cities of the region. As a result, the number of bed days in day hospitals in the region amounted to 774 per 1,000 population or 0.8 per 1 resident per year, with the standard being 557 and 0.6, respectively.

Pre-medical care for the rural population and employees of enterprises is provided by health workers from FAPs, health centers, and emergency medical services (EMS). In total, 706 paramedical workers work in the region at first aid stations, health centers and 893 paramedical workers work in emergency medical care. The number of visits to paramedical staff amounted to 2.6 million, which is 22.6% of the number of visits to doctors, including 1.6 million to paramedical workers of FAPs (including home visits). Ambulance paramedics provided pre-hospital medical care to 345,317 patients during visits, which is 75.3% of the number of patients who received emergency medical care. Of these, rural residents accounted for only 19.0%. In addition, in 3.0% of cases to distant hamlets and villages, the travel time for the SMP ranged from 40 to 60 minutes and in 2.2% - over 60 minutes.

Before the introduction of a diary for recording the work of paramedical workers, we could see only the number of visits using the log of outpatient visits and the book of home visits, and it was small (on average 8-10 visits to the FAP and 1 call to the house). Today, according to monthly reports, we have the opportunity to analyze their work and rationally use them not only to provide pre-medical care, but also to actively carry out preventive work.

In order to study the health status of the assigned population, identify infectious diseases, sanitary educational work, and provide emergency first aid, door-to-door visits were carried out. Door-to-door visits were carried out by nurses from the district network and health workers from FAPs. In 2010, door-to-door surveys covered over 480,000 people. During door-to-door visits, emergency pre-hospital medical care was provided to more than 160

000 patients. Almost all citizens were given recommendations on lifestyle, nutrition, etc.

Thus, due to the remoteness of many settlements in rural areas from healthcare institutions and the lack of road facilities, it is necessary for now to maintain first aid stations, to intensify the work of paramedics in order to provide high-quality pre-medical care to the rural population and carry out preventive work. In remote large villages, it is necessary to open EMS departments (substations) in order to reduce the time it takes to reach the EMS and increase the availability of emergency medical care to the rural population.

The organization and availability of medical care to the population in rural and urban areas of the region has its own characteristics. According to the 2010 All-Russian Population Census, the population of the region as of January 1, 2011 was 1,532,497 people. The entire population is distributed into 1,017 areas (2006 -

1 013). Among them: 429 therapeutic areas (of which 91 are complex and 5 are small); 295 - areas of general (family) practice; 293 - pediatric (of which 1 is incomplete). The staffing of the sites with doctors (individuals) was 91.7%, the remaining sites were staffed by part-time workers. On average in the region there are 1,500 residents per site. 520,023 (33.9%) people live in rural areas. Due to the presence of many farms and villages with a small population, located at a distance from each other and health care institutions, the population at 23 therapeutic sites and GP sites ranges from 2,001 to 2,500 people, at 4 - over 2,500 ( 2006 - 13). At 14 pediatric sites, the number of children ranges from 1,001 to 1,500 (2006 -10). This reduces the availability of medical care to the population of these farms and villages.

Of the total number of visits of the region's population to all specialists (11.5 million, excluding paid visits, visits to dentists and doctor visits at home), the number of visits to the urban population amounted to 8.3 million (72.1%), rural - 3.2 million (27.9%). Attendance indicators for 2010 are shown in table.

Indicators of attendance of urban and rural residents to specialist doctors (per 1 resident per year)

Visits to specialists Urban residents Rural residents (+.- in %) indicator of visits rural/urban.

Local pediatricians 6.2 3.7 -40.3

Local therapists 1.55 1.1 - 29.0

For doctors ORP 0.66 1.3 + 97.0

For narrow specialists 6.0 4.0 -33.3

Thus, the number of visits of rural residents to local pediatricians, local therapists and specialized specialists is on average 34% less than urban ones, which confirms the presence of lower access to primary health care for the rural population. Visits to primary care physicians by rural residents are almost 2 times higher than those of urban residents, since the majority of primary care centers and departments are located in rural areas.

Analyzing the work of general practitioners in Emergency Medicine Centers and departments located in rural areas and emergency physicians in city hospital departments, we observe the following trend.

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2. Pincus, T.M. Increasing the structural efficiency of the regional healthcare system./ T.M. Pincus, M.A. Stepchuk, S.V. Abramova // Problems of economics and management. - Belgorod, 2009. - No. 4. - P.181-183.

3. The effectiveness of the work of general practitioners in the Belgorod region / M.A. Stepchuk [et al.] // Healthcare Manager. - M., 2009. - No. 10. - pp. 12-15.

4. Stepchuk, M.A. Main indicators of the performance of health care facilities and the health status of the population of the Belgorod region / M.A. Stepchuk // Stat. collection. - Belgorod, 2009. - 285 p.

AVAILABILITY OF MEDICAL ASSISTANCE DURING HER PUNISHMENT

M.A.STEPCHUK1 T.M. PINKUS"

S.V. ABRAMOVA1 D.P. BOZHENKO2

Medical information-analytical center, Belgorod Chernyansky central district hospital, Belgorod region e-mail: [email protected]

The authors highlighted the issues of access to health care at the stages of its delivery to Russia and the Belgorod region: the definition of accessibility, the factors affecting its provision, the difficul- ties encountered and their solutions, different levels of access to health care in urban and rural population in the region.

Key words: availability of medical care.

Availability and quality of medical care are ensured by:

1) organizing the provision of medical care based on the principle of proximity to the place of residence, place of work or training;

2) the availability of the required number of medical workers and their level of qualifications;

3) the opportunity to choose a medical organization and a doctor in accordance with this Federal Law;

4) application of procedures for the provision of medical care and standards of medical care;

5) provision by a medical organization of a guaranteed volume of medical care in accordance with the program of state guarantees of free provision of medical care to citizens;

6) establishing, in accordance with the legislation of the Russian Federation, requirements for the location of medical organizations of the state health care system and the municipal health care system and other infrastructure facilities in the field of health care based on the needs of the population;

7) transport accessibility of medical organizations for all groups of the population, including people with disabilities and other groups of the population with limited mobility;

8) the possibility of unhindered and free use by a medical worker of communication means or vehicles to transport a patient to the nearest medical organization in cases that threaten his life and health.

Article 11. Inadmissibility of refusal to provide medical care

1. Refusal to provide medical care in accordance with the program of state guarantees of free medical care to citizens and charging for its provision by a medical organization participating in the implementation of this program and by medical workers of such a medical organization are not allowed.

2. Emergency medical care is provided by a medical organization and a medical worker to a citizen immediately and free of charge. Refusal to provide it is not allowed.

3. For violation of the requirements provided for in parts 1 and 2 of this article, medical organizations and medical workers are liable in accordance with the legislation of the Russian Federation.

Article 12. Priority of prevention in the field of health protection

The priority of prevention in the field of health protection is ensured by:

1) development and implementation of programs to promote a healthy lifestyle, including programs to reduce alcohol and tobacco consumption, prevent and combat non-medical use of narcotic drugs and psychotropic substances;

2) implementation of sanitary and anti-epidemic (preventive) measures;

3) implementation of measures for the prevention and early detection of diseases, including the prevention of socially significant diseases and the fight against them;

4) carrying out preventive and other medical examinations, medical examinations, clinical observation in accordance with the legislation of the Russian Federation;

5) implementation of measures to preserve the life and health of citizens in the process of their education and work in accordance with the legislation of the Russian Federation.

Article 18. Right to health protection

1. Everyone has the right to health care.

2. The right to health protection is ensured by environmental protection, the creation of safe working conditions, favorable working conditions, living conditions, recreation, education and training of citizens, the production and sale of food products of appropriate quality, high-quality, safe and affordable medicines, as well as the provision of affordable and quality medical care.

Article 19. Right to medical care

1. Everyone has the right to medical care.

2. Everyone has the right to medical care in a guaranteed volume, provided without charging a fee in accordance with the program of state guarantees of free medical care to citizens, as well as to receive paid medical services and other services, including in accordance with a voluntary health insurance agreement.

3. The right to medical care of foreign citizens living and staying on the territory of the Russian Federation is established by the legislation of the Russian Federation and the relevant international treaties of the Russian Federation. Stateless persons permanently residing in the Russian Federation enjoy the right to medical care on an equal basis with citizens of the Russian Federation, unless otherwise provided by international treaties of the Russian Federation.

4. The procedure for providing medical care to foreign citizens is determined by the Government of the Russian Federation.

5. The patient has the right to:

1) choice of a doctor and choice of a medical organization in accordance with this Federal Law;

2) prevention, diagnosis, treatment, medical rehabilitation in medical organizations in conditions that meet sanitary and hygienic requirements;

3) receiving consultations from medical specialists;

4) relief of pain associated with the disease and (or) medical intervention, available methods and medications;

5) obtaining information about one’s rights and obligations, the state of one’s health, choosing persons to whom, in the interests of the patient, information about the state of his health can be transferred;

6) receiving medical nutrition if the patient is undergoing treatment in a hospital setting;

7) protection of information constituting medical confidentiality;

8) refusal of medical intervention;

9) compensation for harm caused to health during the provision of medical care;

10) access to him by a lawyer or legal representative to protect his rights;

11) admission to a clergyman, and if the patient is undergoing treatment in an inpatient setting - to provide conditions for the performance of religious rites, which can be carried out in an inpatient setting, including the provision of a separate room, if this does not violate the internal regulations of the medical organization.