Jan Asher, Sean O'Connell, Yulia Urozhayeva McKinsey Bulletin, No. 25, 2012
This and other articles can be read at www.vestnikmckinsey.ru.

For a long time, the effectiveness of medical care in Russia was very low. To remedy the situation, the government has developed a Concept for the Development of the Healthcare System in the Russian Federation until 2020. The reforms carried out within the framework of the Concept are already yielding first results - significant changes are taking place in the structure of the industry. However, the full potential of this program has yet to be revealed. The changes will be so massive that organizations that are not ready for them risk not only missing out on new opportunities, but also abandoning a significant part of today's strategic plans (see Figure 1).

The concept for the development of the healthcare system in the Russian Federation until 2020, developed by the Ministry of Health and Social Development, suggests a significant increase in healthcare spending in Russia. In the case of the implementation of our baseline scenario, by 2015 the volume of annual spending on health care will almost double and reach 160 billion dollars (for comparison: in 2010 it was 80 billion dollars). It is no less important that the Concept will fundamentally change the structure Russian system health care, financing schemes and performance management mechanisms. In the context of these changes, four types of innovations will become especially important, which will ensure the competitiveness of medical organizations. Firstly, this is the transition to a single channel of financing through the Federal Compulsory Medical Insurance Fund; secondly, the clarification of standards medical care and related economic efficiency measures; thirdly, the expansion of funding for a limited number of medical institutions and the freedom of choice of medical institutions for patients; and fourth, increased regional autonomy in health decision-making and more difficult market access for new players.

The set of changes will have a significant impact on the way pharmaceutical companies, medical device manufacturers and hospitals operate, and will determine whether they can realize the economic potential contained in the system. To be successful in this market, participants must be prepared to adapt their strategy to the realities of Russia's new healthcare system.

In this paper, we analyze the most important changes in the Russian healthcare system and their impact on the industry, with a particular focus on pharmaceutical companies and medical device manufacturers. We look at the structural changes that will shape the future of Russian healthcare and highlight the strategic and organizational implications for pharmaceutical companies and medical device manufacturers. We will also focus on the most important issues that market participants need to address in order to adjust their strategy and thereby ensure a future competitive advantage in the Russian healthcare market.

THE HEALTH CARE MARKET IN RUSSIA WILL GROW RAPIDLY AND FULL PLAYER PARTICIPATION IS REQUIRED TO FAST ACTION

According to forecasts, over the period from 2010 to 2015, the volume of the Russian health care market will almost double - from 82 to 155 billion dollars. health care is expected to remain unchanged or even decline (in real terms).

However, market growth in Russia will be uneven across service channels and regions. Thus, according to forecasts, the state Federal Compulsory Medical Insurance Fund (FFOMS) will account for about 60% of the increased spending ($43 billion). Thus, in order to take advantage of this rapid growth, market participants need to quickly adjust their actions in accordance with changes in the structure of the industry and the shift in decision-making responsibility.

In the context of market growth and industry transformation, the Concept provides useful recommendations for achieving the goals set Russian government in the healthcare sector (see Chart 2). To make it easier for companies to structure their government engagement strategy in line with these goals, this document focuses on the major activities outlined in the Concept, which are grouped into three stages of implementation. The first stage has already been completed (it was carried out in 2009-2011); it resulted in a more structured regulatory framework.

Stage 1 is primarily aimed at creating a solid foundation for future improvements. It provides for the development of standards for medical care and the creation of effective regulatory bodies, as well as the adoption of measures to increase the availability of high-quality medical services and launch the modernization of the information system. The changes that will take place in the next phases will affect pharmaceutical companies and medical device manufacturers more strongly. Stage 2 (2012-2015) will change the market structure and increase the efficiency of its participants, in particular, measures will be taken to improve economic feasibility, which will significantly affect the markets for medicines and medical equipment. Phase 3 (2016-2020) will further improve quality control mechanisms and strengthen the autonomy of regional health systems.

Since these reforms will create a more structured market environment, we believe it is critical for market participants to ask themselves two questions. Are they setting goals correctly in a market that will grow at an average of 14% per year until 2015? Do they adequately address the strategic implications of the four major changes in the Russian healthcare system, which are discussed in detail below?

Transition to a single channel of financing through the FFOMS

The transition to a single-channel health care financing system is the most important condition for achieving the government's goals of creating a single national funding organization and improving the economic efficiency of the health care system (see Figure 3). As part of this reform, the FFOMS will account for the largest increase in health care spending in order to form a national financing organization on its basis. Thus, the FFOMS will quickly become the largest public source of health care financing in Russia. This process has already begun in 2011. insurance premiums employers in favor of FFOMS increased by 60% - from 3.1 to 5.1% of the wage fund. Moreover, these contributions were sent in full to the FFOMS, and were not divided between the FFOMS and the territorial CHI funds(TFOMS), as before.

As the budget grows and the capacity of the FFOMS expands, it will assume greater responsibility. So, in January 2011, he was given responsibility for financing emergency medical care. FFOMS is now responsible for such important areas as the treatment of neoplasms, diseases of the endocrine, nervous and digestive systems, as well as the cardiovascular system. Starting from 2013, the financial support of the FFOMS will cover emergency care, and from 2015 - high-tech medical care.

Due to new market trends, pharmaceutical companies and medical device manufacturers need to make changes to their strategy, in particular:

• ensure that the priorities of the FFOMS are fully understood and the economic value of their proposals is demonstrated, as well as an understanding of how the Ministry of Health and Social Development will interact with and coordinate work with the new funder;
• to emphasize cost-effectiveness in their market offer - the experience of other markets with strong national funding institutions, for example, the experience of Germany with the AOK system, indicates the need for this;
• learn how to work in a market where power is distributed among a large number of participants, including FFOMS, the Ministry of Health, the Ministry of Economic Development and others.

• Do we understand how a strong funding organization will affect the development of our area of ​​specialization, including in terms of market access and decisions made at the federal level?
• Do we have a clear understanding of the FFOMS priorities in our areas of specialization?
• How will market access and influencer attitudes towards our company change as pharmaceutical companies and medical device manufacturers need to more convincingly demonstrate the economic value of their offerings?
• How will the emergence and development of a strong national funding organization affect our company's regional strategy?

Refinement of health care standards and related cost-effectiveness measures

Now significant changes and additions are being made to the Russian standards of medical care, aimed at their unification among 83 constituent entities of the Russian Federation. The new standards of medical care adopted at the federal level will determine the methods of treating patients and the drugs and equipment used for this. Thus, there are significant changes compared to the previous situation, when standards were set independently in each individual subject and varied greatly between regions. National standards of medical care are established in accordance with the federal law "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation". It is expected that by 2013, when they come into full force, the level of standardization of medical care throughout the country will increase.

We anticipate that standards of care will greatly facilitate the implementation of cost-effectiveness measures such as health budgeting and the introduction of payment system based on the use of diagnostically related groups (DRGs). To ensure the successful implementation of standards, it is necessary to make their knowledge a prerequisite for the accreditation of doctors. If successfully implemented, they will form the basis for a much-needed analysis of the quality and effectiveness of treatment. They can also serve as a basis for creating an evaluation system that is more result-oriented than the currently used system based on key indicators efficiency, such as the number of beds and their workload, which encourages the creation of redundant infrastructure.

For pharmaceutical companies, it will be especially important to expand the list of vital and essential drugs (VED), which will automatically include drugs specified in the new standards of medical care. In addition to clarifying the list of essential drugs, it is possible to introduce a federal program of drug insurance, which will significantly simplify the access of the general population to drugs with reimbursement of their cost. The total cost of this program is estimated to be between $3 billion and $5 billion. Figure 4 summarizes the most important changes that will affect pharmaceutical companies and medical device manufacturers.

Today, pharmaceutical companies and manufacturers of medical equipment need to take part in the formation of new standards of medical care. They should take important steps, including:

• form a detailed understanding of changes in the standards of medical care and determine their position when discussing policies regarding relevant pharmacotherapeutic groups (PTGs);
• identify key policy makers and decision makers and proactively develop relationships with them, making them a priority source of suggestions and information;
• determine how new standards of care will affect the market offer and the company's strategy.

Key strategic questions to be asked
pharmaceutical companies and medical device manufacturers:

• Does our strategy sufficiently take into account changes in the standards of care?
• How well does our commercial infrastructure fit into the process of changing standards of care? How can we ensure meaningful participation (for example, provide government authorities with clinical information on key FTGs)?
• Does our strategy take sufficient account of the likelihood that changes in the list of essential drugs and in the standards of medical care will affect our product portfolio?

Expansion of funding for a limited number of medical institutions and freedom of choice of medical institutions for patients

The concept for the development of the healthcare system in the Russian Federation until 2020 provides for changes at the level of individual medical organizations. The main amount of funds will be directed to a selected group of medical institutions, while their consolidation will continue, and patients will have the freedom to choose a medical
institutions.

One factor driving the consolidation of health facilities will be increased spending on health infrastructure. If we significantly increase spending on capital infrastructure and modernize information systems for about 40% of hospitals, leaders and outsiders will immediately emerge, and this will contribute to the consolidation of market participants. According to some estimates, up to 25-30% of medical institutions may cease their activities by 2015 (see figure 5).

Also, significant changes in terms of medical institutions will be manifested in the fact that Russian citizens will have more opportunities to choose a treating organization (in accordance with Federal Law No. 326-FZ “On Compulsory Medical Insurance in the Russian Federation”, which also contributed to strengthening the position of the FFOMS). According to the new legislation, Russian citizens can seek medical care at any clinic in the country, while previously they had to go to a doctor at their place of residence. In conditions of free choice of the treating organization, the financing of medical institutions and the salaries of doctors are likely to be closely related to the number of patients served and the achieved effectiveness of treatment.

The direct consequence of this will be that with a decrease in the number of patients, the amount of funding will also decrease - and this again contributes to the consolidation of medical institutions. Hospital leaders are already redefining their priorities and making efforts to attract patients while providing low cost and high quality care. It is this area, according to representatives of medical institutions, that is becoming more and more significant and opens up new opportunities that public health market participants should definitely take advantage of.

The direct implications for pharmaceutical companies and medical device manufacturers are, inter alia, the following:

• The attitude of authoritative specialists and decision makers to the information and educational activities of companies will change significantly; there will be a shift from information about specific products to information about how the overall quality of medical procedures and treatments can be improved.
• The importance of market analysis and segmentation will grow in order to identify priority medical institutions that will benefit from consolidation.
• Market participants will need to actively build relationships with established professionals to provide them with suggestions and help them understand the potential for value creation in the healthcare market.

The main strategic questions that pharmaceutical companies and medical device manufacturers should ask themselves are:

• How well do we imagine changing the priorities of medical organizations? How can we help influencers adapt to new realities as part of our go-to-market strategy?
• Do we have a structured approach to identifying priority health facilities that can benefit from the new environment (for example, health facilities that are currently in the lead or are likely to be in the future)?
• Does our strategy ensure effective partnerships with organizations that will benefit from the new system? Can we understand the new needs of medical institutions that will arise in the new market conditions with the priority of creating value?

Strengthening regional autonomy in decision-making on health issues and complicating market access for new players

At the third stage of the implementation of the Concept, there will be a sharp increase in regional autonomy in decision-making on health issues. This is especially important for market participants, since large independent markets are emerging in many regions - for example, by 2015 the pharmaceutical markets of Siberia and southern Russia will be comparable to the markets of many countries of Central and Eastern Europe or even surpass them in scale.

The consequences of such changes, especially important for pharmaceutical companies, will be that the role of regions in interpreting and applying the regulatory framework in the field of health care will increase, and the differences between them will increase. We have already seen that the laws on promotions of pharmaceutical companies began to be applied differently in different regions. In the future, this will become the norm: the capabilities of companies and the acceptable ways of selling will differ between regions.

As regional decision-making becomes more autonomous, pharmaceutical companies will need to develop and study decision-making frameworks for different regions. At the same time, the participation of authoritative specialists and decision makers should be analyzed, as shown in Figure 6, and the company's strategy should be adapted to the conditions of the region.

As the role of regions in decision-making increases, the growth of companies without an effective regional infrastructure may be at risk. Market leaders will be companies that have established strong relationships with decision makers at the regional level and have the necessary infrastructure to ensure the implementation of the regional strategy.

• Pharmaceutical companies and medical equipment manufacturers need to develop commercial infrastructure in the regions.
• A go-to-market strategy should be locally tailored and provide a structured approach to understanding needs at the regional level.
• There is a need to improve the channel management and stakeholder strategy, placing more emphasis on cooperation with regional distributors and developing sustainable relationships with local authorities.

The main strategic questions that pharmaceutical companies and medical device manufacturers should ask themselves are:

• Does our strategy adequately provide for the development of regional infrastructure and commercial resources?
• Do we have the human resources needed to develop and implement regional programs?
• What do we know about the situation in the regions? What kind of relationships have already been established in different regions?
• Do we have a structured algorithm for evaluating regions and prioritizing them in terms of overall strategy?

The health care sector is set to undergo rapid growth and massive transformation driven by high levels of unmet demand, attention from federal authorities, and a structured reform agenda outlined in the 2020 Vision for Health System Development in the Russian Federation. Major changes will occur in the following areas: financing, standards of medical care, freedom of choice of a medical institution for patients and decision-making.

However, in order to take a leading position in the high-growth market, pharmaceutical companies and medical device manufacturers will have to conduct a comprehensive analysis of the strategy for working in Russia, and possibly re-think it. Companies need to align their work strategy with the Concept and ensure that they fully understand the priorities of the FFOMS and how the creation of a national funding organization will affect market access. The strategy should include the role of companies as a source of proposals in the process of implementing standards of care throughout the country. The strategy should include the establishment and development of relationships with future leaders in the medical services market, as well as understanding the needs of decision-makers in 83 constituent entities of the Russian Federation.

Market participants that do not pay enough attention to any of these aspects are at risk of being left on the sidelines of the dynamic transformation of the healthcare system in Russia. In a rapidly growing market and a rapidly changing environment, pharmaceutical companies and medical device manufacturers are facing a new challenge: they must adapt to the new conditions and change their strategy accordingly - or miss out on huge opportunities.

Table: (Part I)
 

model type	Social insurance	Social insurance	Social insurance
The country	Germany	Japan	Canada
	Health is a factor that determines the quality of "human capital". Medical service - the costs necessary to maintain health.	Medical service is a quasi-public good. Compulsory health insurance programs reimburse part of the cost of medical care.	Medical service is a public good. The health care system should be controlled by the state.
	8,1%	6,6%	8,7%
Sources of financing.	CHI - 60% VHI-10% State. Budget - 15% Personal funds -15%.	CHI - 60% State. budget -10% Public funds - 10% Personal funds - 20%	Federal funds and funds of provincial budgets - 90% Funds of private insurance companies and voluntary donations - 10%.
	Control is carried out by private and public insurers.	Control is carried out by insurance companies - private insurers	The control is exercised by the state.
	90% of the population is covered by CHI programs; 10% - VHI programs; at the same time, 3% of those insured in compulsory medical insurance have VHI.	40% of the population is covered by the national insurance system; 60% - vocational insurance system.	98-99% of the population is covered by CHI programs.
		A wide range of services through a combination of CHI and VHI programs.	Compulsory medical insurance programs provide the necessary set of medical services, the introduction of new methods is limited.
		Demand for a variety medical services stimulates the introduction of new technologies.	Difficult to overcome barriers to the introduction of new technologies.
	Prices are expressed in "points", the price of a "point" is revised when the economic situation changes.	Approved by the Ministry of Health and Social Security.	Regulated by the government, reviewed annually, but changing slowly.

Table: National health care models(Part II)
 

model type	State	State	Market
The country	France	Great Britain	USA
The principle underlying the model.	Medical service is a quasi-public good. Compulsory health insurance programs should reimburse only part of the cost of medical care.	Medical service is a public good. The rich pay for the poor, the healthy for the sick.	Medical service is a private good, i.e. a commodity that can be bought or sold.
Share of health spending in GDP	8,5%	6,0%	14%
Sources of financing.	CHI - 50% VHI - 20% State. budget - 10% Personal funds - 20%	The state budget.	Private insurance - 40% Personal funds - 20% Programs for the elderly and the poor -40%
Control over the effectiveness of spending funds.	Control is carried out by insurers: private insurance companies and state organization social insurance.	Control is exercised by the state represented by the Ministry of Health.	Control is carried out by insurance companies - private insurers.
Availability of medical care	80% of the population is covered by CHI programs.	universal accessibility	Limited by patients' ability to pay, programs for the elderly and the poor do not reach all those in need.
The range of available medical services.	A wide range of services through a combination of CHI and VHI programs.	A wide range of preventive measures, a set of medical services is limited by production capabilities.	A wide variety of curative and preventive medical services.
Use of new technologies.	The demand for a variety of medical services stimulates the introduction of new technologies.	There are no stimulating factors, new methods are introduced slowly.	The largest investment in R&D is in the health sector.
Regulation of prices for medical services.	Regulated by the government, reviewed twice a year.	Financial resources are calculated on the basis of standards that take into account the age and sex composition of the population.	There is practically no regulation. The price is formed as a result of an agreement between the patient, the insurer and the health facility.

 

Let us consider the effectiveness of each of the models from the point of view of the possibility of application in a transitional economy. To do this, let us designate the characteristic features inherent in the economy of the transition period:

1. Scarcity state budget.

2. Decline in production.

3. High unemployment.

4. Low income level of the population.

5. High inflation rates.

In the context of a decline in production and rising unemployment, which entail a deterioration in the quality of life, the need for medical services is increasing. Therefore, the functioning of medical institutions needs, first of all, uninterrupted financing. Consequently, during the transitional period, with the state budget deficit characteristic of it, one cannot count on the effectiveness of the state model for organizing the healthcare system.

The low level of incomes of the population and high rates of inflation will significantly limit the effective demand for medical services on the part of individuals. The decline in production and the orientation towards survival will not allow firms to carry out voluntary insurance of their employees. Therefore, the use of a market model during the transition period will lead to the fact that a significant part of the population will not be able to receive the necessary medical care. This is especially true for such socially unprotected segments of the population as the elderly, the disabled, children, since these are the groups with the lowest incomes, but with the greatest need for medical care. Such negative consequences during the period of economic and political reforms are fraught with a social explosion.

As already noted, during the transition period, people's needs for medical care increase. To ensure the minimum required amount of financing for medical institutions, it is necessary to consolidate all possible sources of raising funds. In the conditions of a state budget deficit and low incomes of the population, only a social insurance model with a multi-channel financing system (from the profits of insurance organizations, deductions from salaries, the state budget) is able to solve this problem.

Historical references

Social insurance began with its simplest types - life and accident insurance, which were handled by small private insurance companies. As industry grew stronger and developed, large enterprises and factories appeared, more and more sections of the population were involved in the insurance process, and health and ability to work became the main object of insurance. In an effort to provide for themselves and their families in the event of disability due to illness or disability, the workers created mutual aid societies, "brotherhoods", and other associations, in which they themselves produced insurance deductions. In this form, the social protection of workers in European countries existed during the XVIII-XIX centuries. For example, in Germany, such a structure has survived to this day in the form of occupational insurance funds (Die Innungskrankenkassen). Small foundations in each city merged into larger and more stable ones.

There were over 5,000 mutual aid societies in France in case of job loss, sickness or retirement. Some of them ran health centers, hired doctors, but more often reimbursed the patient's expenses after a visit by an independent doctor. Similarly, insurance partnerships were created in Great Britain, Austria, Belgium, Switzerland, Russia, the Scandinavian countries and many others.

However, such voluntary structures were constantly in short supply financial resources, and the number of insured was limited, not to mention dependents, the elderly, children and other categories of those in need.

By the beginning of this century, in many European countries ah, laws were passed on insurance of workers in case of illness, disability, old age, and unemployment. According to these laws, in addition to the workers themselves, entrepreneurs, owners of factories and manufactories began to participate in the formation of insurance premiums, paying from 25 to 40% of insurance premiums. At a later period in insurance funds state subsidies and subsidies began to arrive.

The more the state contributed funds (subsidies) to the compulsory health insurance system, the more it controlled this process. The desire to create regulated health insurance has become one of the main prerequisites for the formation of public (budgetary) health care in such countries as the UK, Sweden, Denmark, Ireland and others ("beveridge" model). In Germany, Austria, Belgium, the Netherlands, Switzerland and other countries of Central and Eastern Europe, the so-called "Bismarck" model has spread, in which the financial participation of entrepreneurs who pay mandatory contributions to statutory insurance funds.

Indicative is the reform of national insurance in the UK.

The "National Insurance Act" was adopted in Great Britain on January 15, 1911 and initially, like similar laws in other countries, did not provide for the payment of insurance premiums entirely at the expense of the state, which is the most socially fair form of insurance. The 1911 Act established for one group of insured persons insurance without contributions (the lowest paid workers with earnings of 1.5 shillings per day, who contributed nothing to the society's cash desk, were entitled to all benefits). Benefits to them were formed from the contributions of entrepreneurs, other higher-paid workers, state subsidies. For other categories of the insured, the Act retained the principle of mutual assistance, mitigating it only by prescribing the allocation of subsidies and subsidies from the state budget. Thus, the Act of 1911 for the first time in Great Britain legislated the principle of social solidarity, when the rich pay for the poor, the healthy pay for the sick.

Insurance premiums in Great Britain (as well as in the countries of continental Europe) were collected through the postal departments by buying special stamps, then these funds went to the insurance commissioners in the insurance commissions. The latter distributed the amounts received (in fact, taxes) among all mutual aid societies, depending on the number of insured minus funds intended to replenish the reserve fund and maintain the central insurance bodies.

After less than 2 years (in 1913), the national insurance reform in Great Britain was carried out, as a result of which the state began to cover the costs associated with insurance in case of illness and disability from the budget.

In order for the state to be able to take on such expenses, a relatively broad definition of its competence was needed, bringing the English system of insurance in case of illness and disability to the ideal of insurance - "insurance without contributions", which later became the main prerequisite for the reform of 1948 in Great Britain. and the creation of a budgetary National Health Service.

In France, the issue of organizing health insurance, paying old-age and disability pensions was first raised by the Convention, which created the register - the "Book of National Charity", and the Law "22 floreals of the second year", which determined which categories of the population are subject to entry in this register. But this Law had scarcely been promulgated when the Convention, for financial reasons, refused to carry it out. And only 100 years later, the French government began to implement the principles proclaimed by the French Revolution.

In July 1913, France adopted "a law according to which workers were insured against accidents and occupational diseases. According to this law, the entrepreneur was obliged to pay cash benefits within a calendar year from the moment the employee was dismissed, this issue was decided by a commission that included deputies, employees of insurance institutions, workers and entrepreneurs The law was very important in the development of the health insurance system.

In Sweden, a draft law on social insurance workers was introduced to the Riksdag in 1883. This law was not adopted. In 1907, the Government of Sweden established a special commission chaired by Professor V. Lindstad, as a result of which, on May 21, 1913, the Riksdag adopted the "Law on compulsory insurance in case of illness, disability, old age. "Under this law, all Swedish citizens aged 16 to 66 years had to be insured. Insurance was carried out with the sole purpose of providing for everyone at the onset of old age (67 years), as well as in case of disability ( temporary and permanent) cash benefits from funds received through contributions by the insured and subsidies from communities and the state.About the same period, there was a reform of social insurance laws in Austria, Belgium, Switzerland, Norway, Portugal and other countries where the legislature in to some extent regulated socio-economic relations in the state.

Germany is considered to be the ancestor of sickness funds, where they were formed 30 years before the appearance of the first funds in Russia, and the German das Krankenversicherungsgesetz became a model for the preparation of the Law on social insurance of workers in case of illness, adopted by the III State Duma on June 23, 1912 in Russia .

As early as 1883, immediately after the adoption of das Krankenversicherungsgesetz, sickness funds began to form throughout Germany: factory, construction, communal, local, etc. The experience of their activities showed that large funds incomparably better provide all types of assistance to their members than small ones. Therefore, since 1885, the process of unification and centralization of sickness funds began, their reorganization into local (city) sickness funds. The largest of them were Leipzig, Dresden, Munich, Stuttgart.

For example, in Leipzig, 18 local funds and one communal fund were formed, with 22,800 members. Thus, the local health insurance fund for Leipzig and the surrounding area (Ortskrankenkasse fur Leipzig und Umgegend) was born - the largest health insurance fund in Germany. For the provision of medical care (in the period 1910-1913), the cash desk entered into contractual relations with 429 doctors, including 13 polyclinics, 143 narrow specialists and 28 dentists.

The cash desk maintained its own sanatoriums and the Zander Institute, where there was an X-ray room, electro- and light therapy. She was in contractual relationship with 59 pharmacies, 29 optical shops and other institutions. Patients had the right to freely choose a doctor from a list of doctors published by the cashier who worked with her under a contract.
- The duties of health insurance companies according to the law included:

Providing free treatment;

Payment of cash benefits during illness;

Financial assistance and allowance for pregnant women and women in childbirth;

Burial allowance.

Family members of the insured were provided only free treatment, as well as medical care for pregnant women and women in childbirth. But most of the cash desks did not limit themselves to this and expanded their assistance through preventive measures (sanatoriums, rest homes, boarding houses, etc.), and also allocated special emergency funds to help the disabled, thus creating a replacement for the missing old-age and disability insurance. The funds of the sickness funds were: 2/3 contributions from the workers themselves and 1/3 contributions from entrepreneurs. Thus, several types of organization of medical care for the insured have historically formed: a system of free choice of a doctor; system of "listed doctors"; a system of doctors permanently working in sickness funds under contracts.

A vivid example of evolutionary development is shown by Norway with the introduction of public health insurance (Public health insurance):
1909 - the beginning of the development of the first necessary legislative acts;
1911 - the beginning of practical implementation;
the formation of the system - by 1956. But only in the last 4 years (by 1999) health insurance began to cover the entire population of the country.

Each of the systems had its advantages and disadvantages and was applied depending on the established traditions, socio-economic and geographical features of the given territory.

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Public health model in Russia

The term “public health” (“public health model”) is a relatively new phenomenon for Russia, while medical workers in most developed countries do not imagine other conditions for the performance of their profession.

The Western model of public health in a simplified form is presented as a kind of social contract between the state (state regulator: ministries, departments, etc.) and the professional medical community (non-state regulator: associations, chambers, guilds, etc.) on the delimitation of powers (rights, duties and responsibilities) on key issues medical support population. Despite the fact that the mechanisms and levels of delimitation of powers, the procedure for interaction, institutional forms of state and non-state regulators in the field of healthcare in different countries have their own historical and national characteristics, all of them are united by a single approach to the performance by doctors and nurses of their profession: professional medical activity (at least in such aspects as standards, programs of higher and postgraduate continuing education, certification and / or attestation, corporate ethics, professional liability insurance) is regulated by professional associations in medical specialties, general corporate (interdisciplinary) issues at the level of territorial units of countries (land, region, province, state) are regulated by territorial medical associations (for example, Florida Medical Association, Inc.), and at the state level - national medical associations (eg Bundesarztekammer). With this construction of sectoral regulation, the state regulator performs representative, supervisory, control and licensing functions, and, as a rule, not in isolation, but with the interaction and / or direct participation of various structures (committees, commissions) of professional medical associations. Upon receipt of a certificate (certificate) issued by a professional medical association, a medical worker (doctor, nurse) acquires the right to independently perform the chosen profession, and the state (state regulator) is obliged to ensure the implementation of this right by issuing him a license. This legal mechanism creates the conditions under which the legal personality in relation to medical activities (medical and diagnostic process) has only a doctor (nurse), and not a medical organization, since only to an individual at the same time, the main elements of the concept of "legal personality" are applicable: legal capacity, legal capacity and delinquency.

The model of public health suggests variants of labor relations between the owner of medical organizations (whether it be the state or an individual) and medical personnel, which are unusual for Russian reality. The role of the owner's representative in the hospital consists mainly in monitoring the effective exploitation of the owner's property by the labor collective (trade union) of medical workers in their medical activities, and signing a collective agreement with the trade union of this medical organization. It is the trade union of a particular medical organization that acts as an economic (economic) entity in legal relations both with the owner of the hospital and with insurance organizations, suppliers of medicines, medical equipment, etc. (concludes contracts, issues and/or pays invoices, keeps records of working time, issues wages etc.).

Responsibility for the quality of medical care under the public health model rests primarily with the bearer of the profession - a doctor (nurse), and also - with the structure that regulates their professional activities - professional associations in medical specialties. The high level of quality of performance by a doctor (nurse) of his profession is determined by many factors, the main of which are carefully developed standards of activity in all medical specialties and control over their implementation by professional medical associations, a rigid system of continuous postgraduate education with a subsequent certification procedure, a system of corporate ethics and professional liability insurance (the amount of annual insurance in favor of third parties in some specialties exceeds $ 1 million). The participation of state regulators in the system of measures to improve the quality of medical care is, as a rule, either formal (a license is issued only with a certificate/attestation) or indirect in nature, for example, through funding funds that insure the professional liability of doctors, investing in promising scientific research, etc. .d. A high degree of protection for the patient and the doctor in conflict situations is achieved not so much by the work of the judiciary, but by the vigorous activity of various public (extrajudicial) institutions that have broad powers due to their legitimacy.

From the point of view of the scientific theory of regulation, the Western model of public health, in terms of the performance of professional medical activities (that is, what is not regulated by the state regulator), can be considered as an industry version of self-regulation. In the historical aspect, the appearance in economic activity countries of various forms of regulation (state regulation, self-regulation, co-regulation, market regulation) is explained by economic feasibility, the desire of society to increase the efficiency of production of public goods. The nature of the produced public goods largely determines the specifics of the regulation of their production and consumption. Medical services belong to the category of experienced and/or trusted goods, i.e., just to those categories of goods that require self-regulation of the activities of their producers. In other words, Western society considers the public health model, in which self-regulation of the professional medical activities of doctors (nurses) is a mandatory and essential element, as the most efficient and cost-effective option for the production of medical services. Society benefits from this model, including on such grounds as reducing the cost of maintaining the state regulator, which is very relevant for Russian reality: in terms of the share of direct and indirect costs of maintaining the structures and representatives of the state regulator (officials) in the country's consolidated healthcare budget, Russia is undoubted "leader" among European countries. In addition, today self-regulation as an institutional mechanism for regulating the production of public goods in a particular area is usually considered as the most effective "medicine" in the fight against such vices of another institutional mechanism - state regulation, as corruption and bribery.

Concluding a brief description of some average Western model of public health, it must be said that the structure of the public health of a particular state is always a mirror image of the structure of the social structure of this state. The main element of the public health model is the professional medical community, structured horizontally (according to medical specialties) and vertically (territorial and national levels), regulating the professional activities of its members on the principle of self-regulation. A reasonable balance between state and non-state regulators in the healthcare sector ensures the optimal distribution of resources in the industry, the availability and quality of medical care acceptable by society, high social and legal protection for both doctors (nurses) and patients. The legitimacy of professional medical associations, as well as the public health model itself, in Western countries is not secured by any normative documents direct action. The public health model, as an international sectoral project of voluntary self-regulation, was formed evolutionarily, based on economic practice and common sense. The legitimacy of professional medical communities in this model is determined by many years of historical experience of their functioning, structuredness and membership in associations (de jure - voluntary, and de facto - mandatory).

The increased interest in the public health model in Russia in recent years was associated primarily with an attempt to carry out administrative reform in the country, the main objective which (according to the plan of its "architects") - "correction of the forms of state intervention in the economy, the rejection of excessive bureaucratic regulation and increasing the efficiency of state power in those areas where its participation is absolutely necessary" (5). The main direction of eliminating total state interference in the economy in the Program provided for the development of self-regulation of economic activity. If the package of laws of the so-called “first wave” of debureaucratization adopted in 2001 (“On state registration legal entities”, “On Licensing Certain Types of Activities”, “On Protection of the Rights of Legal Entities and individual entrepreneurs when conducting state control (supervision)") did not introduce significant innovations in the functioning of the healthcare industry, then the adoption of the laws of the "second wave" of administrative reform - the stage of deregulation of the economy itself - would provide the legal framework for the transition from the administrative-state model to the model of public health in Russia. Of the two most important laws of this stage, only one was adopted - the federal law "On Technical Regulation", the second - the draft federal law "On Self-Regulatory Organizations" - has not been considered by the State Duma for the third year (in the first reading, the bill was adopted on 14.10.2003). The Federal Law "On Technical Regulation" from July 1, 2003 removed from direct state regulation the main element of the performance of the profession is the standards of professional activity, secured the right of professional associations to develop organization standards and the voluntariness of their implementation, instead of mandatory accreditation of business entities, approved a system of voluntary certification of conformity, etc., i.e., actually determined the functions transferred to the professional community (to a non-state regulator), laid the foundation for the formation of delegated self-regulation of professional activities in various fields, including healthcare. The adoption of the Federal Law “On Self-Regulatory Organizations” would make it possible to legislate in the Russian Federation a public health model in which, as mentioned above, the professional medical community manages the professional activities of its members, and various institutional structures of the state regulator (Ministry of Health and Social Development, federal Service on supervision in the field of healthcare, etc.) perform only supervisory and control-permissive functions.

Often, opponents of the introduction of delegated self-regulation in Russia through the adoption of a special law refer to the fact that none of the Western countries have similar laws. Indeed, Western self-regulation, including in the healthcare sector, was voluntary, but it should be remembered that it was formed evolutionarily and, as regulatory theorists say, from scratch. In the context of long-term total state regulation and the Russian mentality, the transition to effective self-regulation, especially in the social sphere, is possible only through the adoption of a federal law: either general or special for a particular industry. This is confirmed by the successful experience of introducing delegated self-regulation in Russia through the adoption of special laws in such areas as advocacy, notaries, appraisal activities, bankruptcy, etc. the ministry, not the chief lawyers (chief notaries) of the country and / or the subject of the federation, but the formed bar associations (notary chambers), i.e. non-state regulators. Without going further into the discussion about the significance, essence and expediency of the adoption of the law "On Self-Regulatory Organizations", it is only necessary to note that:

• 1) in the context of long-term total state regulation, the formation “from above” (i.e., through the adoption of a law) of a model of public health and self-regulation of professional medical activity - in particular, should be considered as a “prognostically favorable” sign of the maturity of the state in matters of social responsibility for effective reproduction public goods (in particular - medical services);
• 2) The transfer of functions for the real management of professional medical activities into the hands of professional associations should be considered, first of all, not as their benefit, but as the emergence of a real personal responsibility of each member of these professional associations to the patient and society as a whole for the final results of their activities.

The current state of the progress of administrative reform in the healthcare sector is highly uncertain and inconsistent. Instead of systematic work on the formation of a public health model in Russia, the society is offered programs that are nothing more than an attempt to “reanimate” the outdated and discredited administrative-state model of industry management throughout the world. Moreover, there are "prognostically unfavorable" signs of curtailing reforms, including in the healthcare sector. From 01.01.2006 amendments to the "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" came into force, according to which the standards of medical care can be federal and regional, and are approved by the executive authorities, i.e., the state regulator of the appropriate level. In 2005, Roszdravnadzor took steps to "regulate" the system of voluntary certification of conformity (until 07/01/2003 - accreditation) through non-profit organizations. The presence in these documents of the phrase "... the results of certification... will be taken into account by the territorial bodies of Roszdravnadzor when conducting quality control ... and re-licensing" is nothing more than a signal to participants in the medical services market about a return to the old "rules of the game": voluntary de jure The “voluntary conformity certification system” of medical organizations will gradually turn into a de facto mandatory procedure in the licensing process.

In accordance with today's legislation, in particular - Article 54 of the Fundamentals of Legislation ..., professional associations can actually manage only one of the previously mentioned elements of professional activity - the certification of their members. All attempts by the state regulator (Ministry of Health) to de jure “privatize” this function with the help of departmental regulations were unsuccessful (Order of the Ministry of Health and Medical Industry of the Russian Federation dated December 19, 1994 N 286 “On approval of the Regulations on the procedure for admission to the implementation of professional (medical and pharmaceutical) activities” and the Order of the Ministry of Health and Medical Industry of the Russian Federation dated November 17, 1995 N 318 “On the regulation on the qualification exam for obtaining a specialist certificate” were canceled in 2000), however, de facto, as we all know, certification is not one of the elements of the activity of professional medical associations.

In the context of legislative “throwing” and various kinds of conflicts of law arising in connection with this, the question will naturally be: is it possible to build a model of public health in Russia and what is the role and tasks of the professional medical community in this process? The historical experience of developed countries shows that the public health model is an obligatory attribute of most civilized states. The steps taken by the political leadership of Russia to democratize the economic and social sphere, the fight against corruption and bribery in the structures of state regulators, serious intentions to participate in international economic projects (such as the World Trade Organization) enable the authors to talk about the inevitability of reforming domestic medicine towards public health models. Obviously, it's a matter of time.

At the same time, it should be remembered that the process of forming the institution of self-regulation, and in fact, the process of redistributing powers and responsibilities between state and non-state regulators, will be accompanied by increased requirements for the structures of the non-state regulator - the professional community. And this is quite logical. It is not uninteresting for society, represented by the state regulator, to know the answers to at least two questions: in whose “hands” should the powers be redistributed and how will the non-state regulator be responsible for the exercise of these powers to society and the end consumer, in particular, to the patient? In other words, what is the professional medical community in Russia today, how ready is it both structurally and functionally to manage the professional activities of medical workers? The answers to these questions, which are essentially part of our study, cannot be comprehensively covered within the framework of this article. It can only be said with certainty that today's problems of the formation of a civilized professional medical community are the essence of a mirror reflection of the problems of our society as a whole. The uncertainty of the future territorial structure of the country, the lack of a clear strategic plan for the development of national healthcare with a horizon of 10-15 years, sectoral legislation “fluctuating along with the party line”, combined with existing conflicts of law, do not contribute to the systematic creation and functioning of institutions of the professional medical community, moreover, give rise to methodological and methodological obstacles to this process, stimulate social and professional apathy of medical workers, disbelief in the prospects for civilized forms of performing their profession. At the same time, the efforts of national healthcare leaders in most medical specialties within the framework of the activities of the Russian Medical Society give hope for the inevitability of building an adequate professional medical community in our country, just as the experience of the development of Western democracies indicates the inevitability of creating a public health model in Russia. A striking confirmation of this is the creation and vigorous activity of such all-Russian public organizations as the Russian Society for Emergency Medicine, the Russian Association of Transfusiologists, the Russian Society of Surgeons, the Russian Association of Nurses and others. Obviously, this is also a matter of time.

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The Russian authorities pay for the fact of providing medical services, and not for their result, according to a report by The Economist Intelligence Unit. This puts domestic healthcare on a par with the medicine of third world countries.

The Russian healthcare system focuses not on the result of treatment of citizens, but on the number of medical services provided. This conclusion was made by the experts of the international analytical company The Economist Intelligence Unit (EIU). In their opinion, in this parameter, Russia is similar to Egypt, Indonesia, Nigeria, South Africa, the United Arab Emirates and Brazil.

EIU is the analytical division of the British media holding The Economist Group, which includes the magazine of the same name. EIU deals with economic, political and socio-demographic forecasts. The company has developed a rating of countries in terms of quality of life, in which Russia ranked 72nd out of 80.

Analysts compare health care systems in 25 countries with an ideal model, which they call value-based. In this model, the state pays for the results of the patient's treatment, and not for the medical services provided.

This is the first such review from the EIU. The experts studied how government spending on patient care correlates with the results of therapy. For the study, 17 parameters were selected: for example, the availability of medical care for all segments of the population, the general policy of the state in the medical field, the system of clinical recommendations, on the basis of which doctors choose the appropriate treatment, and the training of medical staff.

Russia received a high score only for coverage of the population with medical care. For all other parameters, the scores are medium and low. The minimum score was zero, the maximum score was four.

State insurance in Russia does not cover all types of medical care, does not provide the population with all the necessary medicines, and the quality of treatment in some cases leaves much to be desired, the report says. Cost-cutting measures have led to the closure of small medical facilities and a decrease in the amount of insurance coverage under compulsory medical insurance, the EIU concludes.

Among good points experts noted the development of the Moscow Unified Medical Information and Analytical System, which allows you to make an appointment with a doctor and view the schedule of medical institutions online. Several hospitals have moved from paper-based records to IBM Lotus Notes electronic health records. The EIU also drew attention to the launch of the capital's electronic medical records service as part of the Information City program.

Based on the results of the study, 17 parameters were combined into four categories, the success of states in each of which was assessed as low, medium, high and very high.

For each of the four outcome parameters, Russia received the lowest scores. This is due to the fact that payment for medical services in the country does not depend on the results of therapy, and the authorities do not analyze how money is spent on medicine. In addition, the various elements of the health care system are loosely linked.

The only country with the highest score is Sweden. The UK is next. Most countries received low and medium scores.

The Ministry of Health did not agree with the conclusions of the EIU that the situation in health care has worsened due to cuts in funding. In recent years, the volume of mandatory medical insurance has increased, RBC was told in the press service of the department. In 2014, it amounted to 1 trillion 174 billion rubles, in 2015 - 1 trillion 414 billion rubles, in 2016 - 1 trillion 459 billion rubles. In 2017, the Ministry of Health plans to spend 1 trillion 613 billion rubles.

It is impossible to tie the financing of the Russian healthcare system to the result of treatment, Alexander Saversky, president of the League of Patient Defenders, believes. This will lead to falsifications: medical institutions will successfully "treat" healthy citizens on paper and receive money for it, the expert is sure.

There is such a problem even now: polyclinics and hospitals receive payment for the medical services provided, therefore they attribute visits and procedures to citizens that they did not perform and did not receive. In this regard, there should be three criteria for assessing health care: mortality, morbidity and patient satisfaction, Saversky summarizes.