Data from 2014 to 2018, the upper dotted line is based on forecasts (if the situation does not improve), and the lower dashed line is based on the forecasts of the State Program for Health Development. The “new” EU countries include the Czech Republic, Estonia, Hungary, Poland, Slovakia, Slovenia ( close to the Russian Federation in terms of GDP - 23-25 ​​thousand $ PPP per capita per year). Sources: Rosstat database - EMISS; the WHO Health for All database; OECD database "OESD.StatExtracts"; Demographic Yearbook of Russia (2014).

The most important lesson of these periods - the improvement of the socio-economic situation of citizens, the increase in state funding for health care, the implementation of targeted health programs and the political will of the country's leaders - makes it possible to achieve a noticeable improvement in the demographic indicators in the country. Standardized mortality rate (SCR).

Standardization of mortality taking into account the age structure of the population will give an even greater difference in values ​​with the EU countries than a comparison according to the ACS. SDR from all causes in the Russian Federation is 1.5 times higher than in the 6 indicated "new" EU countries, and 2.1 times higher than in the "old" EU countries (respectively 1109, 755 and 523 cases per 100 thousand population). population). At the same time, SDR from diseases of the circulatory system is 1.7 times higher than in the "new" and 3.6 times higher than in the "old" EU countries (570, 345 and 160 cases per 100 thousand population, respectively) .

morbidity of the population. In the last 16 years, the overall incidence of the population of the Russian Federation has been constantly growing, which is explained, on the one hand, by an increase in the proportion of the elderly population and more effective detection of diseases using new diagnostic methods, and on the other hand, by the deterioration of public health and the ineffectiveness of the system for preventing and treating diseases.
In 1990, 158.3 million cases of diseases were registered (detected), in 2013 - 231.1 million, i.e. the growth was 46% (and in terms of 100 thousand population, the incidence increased by 51%) (Fig. 4). The observed increase in morbidity correlates with the increase in mortality during this period.

On fig. Table 4 shows that from 1990 to 2013 the number of cases of diseases leading to death increased, for example, the number of diseases of the circulatory system increased by 2.3 times, oncological diseases - by 2 times. The frequency of the pathology of the musculoskeletal system and connective tissue leading to disability - 2.3 times, as well as complications of pregnancy, childbirth and the postpartum period increased 2.2 times. It should be noted that the actual incidence requiring medical intervention may be even higher than the recorded one. This is due to the fact that part of the population, due to the low availability of medical care, especially primary health care, simply does not apply to medical institutions. This is confirmed by the results of the medical examination conducted in 2013, when 34.6 million people were examined and the number of people under dispensary observation doubled.

Figure 4. Dynamics of general morbidity in the Russian Federation per 100,000 population (total population and by disease classes) from 1990 to 2013

The basic problems of the health care system of the Russian Federation are growing

Figure 5. Availability of practicing doctors in the Russian Federation (2013) and developed countries (2012)

The "new" EU countries include the Czech Republic, Estonia, Hungary, Poland, Slovakia, Slovenia (close to the Russian Federation in terms of GDP - $23-25 ​​thousand PPP per capita per year).
Sources: Rosstat database - EMISS; the WHO Health for All database; OECD database "OESD.StatExtracts"; Federal form of statistical observation No. 17 "Information on medical and pharmaceutical workers in the Russian Federation for 2013", TsNIIOIZ.

Figure 6. Insufficient drug provision of the population on an outpatient basis - in the Russian Federation 4.2 times lower than in the "new" EU countries

Low volumes of VMP - 3-5 times lower than in the "new" EU countries. For example, revascularization operations are performed 3 times less (respectively 89.4 and 253.2 per 100 thousand population), knee and hip replacement operations are 3.8 times less (respectively 58 and 220 per 100 thousand population).

The quality of medical care remains unsatisfactory. The indicators of the quality of medical care in the Russian Federation are worse than in the EU countries, which is caused by a critical weakening of the system of training in medical universities and insufficient implementation of a modern system of continuous medical education. For example, the in-hospital mortality rate of patients with myocardial infarction in the Russian Federation is 2.4 times higher than in the EU countries on average (17 and 7%, respectively). In the Russian Federation, non-compliance of the provided medical care with the established standards and rules, according to the MHIF, occurs in every sixth case of treatment (17%), in developed countries, compliance with the established standards of treatment and clinical recommendations) is 90% (and only in 10% of cases there are deviations) , i.e. we have this figure is almost 2 times worse.

The already insufficient public funding of the health care system is being reduced. In 2013, public spending on health care was 1.5 times lower than in the “new” EU countries (910 and 1410 $PPP per capita per year, respectively, Fig. 7). In 2014, compared to 2013, public expenditures in constant prices decreased by 9%, and in 2015, the deficit of funds, taking into account inflation (12.2%), the devaluation of the ruble (60%) and the additional expenditures already declared by the Ministry of Health on compared to 2014 will be almost 30% (without taking into account the need to increase salaries for medical workers - 20%). Additional expenses consist of funds needed to increase the volume of high-tech medical care (HMP) for 162.5 thousand citizens, to provide guarantees of free medical care to new citizens of the Russian Federation - 2.3 million people, to increase the wages of medical workers in accordance with the Decree of the President of the Russian Federation No. 597 dated May 7, 2012, as well as to cover the accumulated deficit in 2014. Together, these expenses amount to 873 billion rubles. (without increasing the remuneration of medical workers - 645 billion rubles). And the planned increase in spending on the State Guarantee Program (SGBP) in 2015 compared to 2014 is only 173 billion rubles. The difference (deficit) is 700 billion rubles. (873 – 173), this is 30% of all spending on the SGBP in 2015 (2205 billion rubles). In other words, we planned funds 30% less than necessary.

The effectiveness of spending the resources of the health care system of the Russian Federation is decreasing. In 2014, healthcare funds are allocated for capital and other non-priority expenditures. For example, for the construction of perinatal centers at the expense of compulsory medical insurance, which reduces costs in the most deficient system of compulsory medical insurance. The development of prophylactic medical examination in a situation of shortage of personnel in the primary care is ineffective, since doctors cannot take on the additional workload.

There are significant external challenges up to 2020 that need to be taken into account when formulating health care development policy

Demographic: decrease in the number of able-bodied population by an average of 1 million people. in year; growth in the number of citizens older than working age by 4.3 million; increase in the number of children by 7%. As a result, it is necessary to provide special programs for providing medical care to these categories of the population.

Economic: worsening socio-economic indicators of the country's development in 2015 - a fall in GDP by 3%, inflation to 12.2%, devaluation of the average annual exchange rate of the ruble against the dollar by 60% (in 2015 compared to 2014), falling real incomes of the population by 4%.

Main conclusions about the relationship between public health financing and public health indicators in the Russian Federation and developed countries

An analysis of the existing proposals for the development of health care shows that their implementation will not improve the health indicators of the population of the Russian Federation by 2018.

On May 7, 2012, Decrees of the President of the Russian Federation (Nos. 596, 597, 598 and 606), which are the most important for the industry, were adopted, aimed at increasing the remuneration of medical workers and faculty of medical universities, increasing the provision of medicines to the population and developing prevention. They also set a goal for health care - to achieve a life expectancy of 74 years by 2018. However, the measures for the implementation of these decrees proposed in the "road maps" will not improve the quality and accessibility of medical care and improve the health indicators of the population of the Russian Federation.

Thus, the "road maps", on the contrary, provide for a reduction in the volume of emergency and inpatient medical care under the SGBP, a reduction in medical personnel, and an increase in paid medical services in state medical organizations.

Management and budgetary maneuver in the development of the health care system of the Russian Federation until 2018.

Figure 8. Two scenarios for financing healthcare in the Russian Federation until 2020 – “survival” and “baseline”

• Implementation of Presidential Decrees to increase wages for employees of state and municipal medical organizations.

• Providing benefits to medical workers in primary health care for the purchase of housing.

• Indexation of salaries for rural medical workers (coefficient of 1.4 to the average salary of medical workers in the country).

• Training of personnel in medical and pharmaceutical universities: to increase the remuneration of the teaching staff (coefficient of 2.0 to the average salary of doctors in the country), to improve their qualifications (10% of the salary fund (payroll) of the teaching staff), for subsidies to medical organizations for the placement of clinical bases of universities, as well as for the material and technical equipment of universities.

• Development of a system of continuous medical education - advanced training (1% of the payroll of medical workers, as is customary in most developed countries).

• Inclusion in the tariff for payment of medical care of the expense item for depreciation and maintenance of expensive equipment and maintenance of the software and hardware complex (HSC) of medical organizations.

• Drug provision of children aged 0 to 15 years on an outpatient basis.

• Medicinal provision on an outpatient basis for citizens of working age suffering from diseases of the circulatory system.

Consequences of reducing the volume of state financing of health care in the Russian Federation

Funds provided by the Ministry of Health for health care at constant prices (2013 - 100%) in 2015 are reduced by 13% (excluding declared additional expenses in 2015 and the devaluation of the ruble), in 2016 - by 17%, in 2017 - by 16%, in 2018 - by 15%. This means that guaranteed volumes of medical care will also decrease by the same amount. All this, in the situation of a decrease in real incomes of the majority of citizens of the Russian Federation (by 4% in 2015, according to the forecasts of the Ministry of Economic Development), will lead to a decrease in the availability and quality of medical care for the population of the Russian Federation, and hence to a deterioration in the health of the population.

The deterioration of the socio-economic situation of citizens, the growing funding gap and the reduction in the capacity of the healthcare system in 2015 has already led to an increase in mortality by 5.2% in the first quarter. In subsequent years, if the basic problems of the industry are not resolved, instead of the planned decrease, mortality will increase. According to the most optimistic forecasts, in 2018 it will grow to the level of 13.9 cases per 1000 population (see Fig. 3). It follows from this that by 2018, instead of reaching 74 years of life expectancy, this indicator will fall from the current 71 years to the level of 69–69.5 years. This means that the Russian Federation will no longer be included in the list of 50 developed countries of the world whose life expectancy is more than 70 years. And we were so proud of this achievement in 2013-2014!

It should be noted that the implementation of the basic program will require the political will of the country's leadership. The key to the successful implementation of programs is the accelerated and massive professional development of senior personnel in healthcare, as well as the formalization and tightening of requirements for their appointment to managerial positions.
Thus, in order to save the lives of Russian citizens, and hence to ensure the national security of our country, it is necessary to increase public funding for healthcare and focus on solving the basic problems of the industry.

The transition from the paternalistic (total guardianship) system of the Soviet state to the liberal model in the healthcare sector had negative consequences. The changes had a very negative impact on the health of Russians - it became worse compared to the Soviet period. In recent years, a vicious circle has emerged in which domestic healthcare has found itself: the more money is invested directly in medicine (in specialized inpatient care and high technology), the less money remains for prevention and early detection of diseases. The lack of prevention predetermines the growth in the number of patients, the detection of diseases in the later stages, and the chronicity of pathologies. This, in turn, requires even more investment. This leads to a number of complex social problems of Russian health care:

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

Increasing the cost of health care does not increase its effectiveness;

The increase in paid medicine, the constant shortage of funds, the lack of transparency of financial flows;

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

The sharp economic stratification of Russians, which predetermines an unequal attitude to health and opportunities to receive medical care;

Inequality in the income of doctors themselves;

Shifting the responsibility for health only to the population itself.

The main negative consequence of these problems is an unprecedented reduction in the number of the population in peacetime. Today, this is no longer such a devastating process as in the previous 18 years. There are tendencies to stabilize the population, but the "quality" of people's health, habitat degradation, a critical decline in the country's labor and defense potential are actual threats. The demographic situation in the Russian Federation is still unfavorable, although the rate of population decline in recent years has significantly decreased - from 700 thousand people annually in 2000-2005 to 213 thousand - in 2007. In 2008, the rate of natural population decline was 2.7 per 1,000 population. As of 2010, the resident population in the Russian Federation was 141.9 million people. The decrease in the rate of population decline is mainly due to the birth rate and the decrease in mortality. In 2007, 8.3% more babies were born than in 2006 (1 million 602 thousand). In 2006, for the first time in 7 years, life expectancy began to increase - from 65.3 years to 67.5 years. However, the average life expectancy in Russia is 6.5 years less than that of the "Young Europeans" (countries that have joined the EU since 2004) and 12.5 years less than in the countries of "Old Europe". A large difference in Russia remains in the life expectancy of men and women - 13 years. The main reason for this is the high mortality of men of working age. Life expectancy is a widely accepted indicator of quality of life and health and a valid measure of mortality. The main cause of death in Russia are:

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

Neoplasms (13.8%)

External causes (11.9%).

It is significant that cancer

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

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

Excessive consumption of strong alcoholic beverages;

road accidents;

Suicide.

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

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

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

Development of primary health care;

Strengthening preventive activities;

Increasing the availability of high-tech assistance;

Introduction of the birth certificate system.

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

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

The birth rate increased by about 16%;

Increased life expectancy by 2.2 years;

Decreased overall mortality rate by 10%.

State intervention, increased funding, and finally, the personal control of the first persons in this situation can be converted into a figure of 500,000 saved lives of Russian citizens.

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

Two serious government documents were approved by the President and the Government of the Russian Federation - "The concept of the demographic policy of the Russian Federation for the period up to 2025" and "The concept of long-term socio-economic development of the Russian Federation for the period up to 2020". The latter document applies to all sectors, including healthcare. It sets goals: to reduce the death rate by 1.5 times by 2020 and increase life expectancy to 73 years. The main principles of this strategy should obviously be:

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

Equality of residents of the city and the countryside, rich regions and depressive;

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

No corruption.

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

QUESTIONS AND TASKS.

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

2. What parameters determine the health of a person?

3. List the main actors in the healthcare system.

4. What are the main problems of healthcare in the Russian Federation.

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

6. How do the states of the ecosystem and human health correlate?

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

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

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

Chapter 11. SOCIOLOGY OF THE FAMILY AND MARRIAGE.

1. Family as a social institution and social group.

2. The emergence and historical types of the family.

3. Typology of the modern family.

4. Social functions of the family.

5. Family life cycle.

6. Family structure and types of family relationships.

7. The institution of marriage.

8. Problems and prospects for the development of family and marriage relations.

Basic concepts: sociology of family and marriage, family group, family structure, social functions of the family: reproductive, educational, economic, recreational, social status, regulatory, medical; family life cycle, family types: traditional, neotraditional, egalitarian, partnership, extended, patriarchal, incomplete, nuclear, childless, large; marriage, types of marriage: endogamy, exogamy, polygamy, polygyny, polyandry, monogamy, early marriage, child marriage, purchase-redemption, church, legal (civil); family law: marriage, rights and obligations of family members, forms of responsibility, divorce, motives and reasons for divorce.

FAMILY AS A SOCIAL INSTITUTION AND A SOCIAL GROUP.

The family is one of the main foundations of society and one of the most important human values. This is a complex social formation in which diverse forms of social relations are intertwined and which performs numerous functions necessary for society and man. The family can be considered as a social institution and as a small social group.

Family– it is a social group that has a common place of residence, economic cooperation, a system of social and emotional relationships. A family includes adults of both sexes who engage in socially sanctioned sexual intercourse and usually have one or more children (own or foster).

As a small social group, a family is a collection of people united by marriage or consanguinity and having coinciding interests in the field of organizing everyday life, mutual assistance and mutual responsibility for the health and well-being of family members. It combines a whole range of interests and relationships of various kinds: emotional, spiritual, economic, sexual, etc. This is the most cohesive and stable cell of society, the group with which a person always keeps in touch.

how social institution, it includes a set of roles and statuses, norms, values, sanctions and patterns of behavior that regulate relationships between spouses, parents, children and other relatives. The family is the main institution of human society. This institution includes several more private institutions: marriage, kinship, motherhood and paternity, property, etc. In turn, the institution of marriage includes the institutions of courtship, matchmaking, betrothal, etc.

In addition to sociologists, the family is studied by historians, economists, ethnographers, lawyers, politicians, demographers, and even recently emerged disciplines that claim a synthetic approach - "surname science" and "feminology". Hence the significant differences in the definition of the very concept of "family".

Yes, in terms of sociology A family is a small social group based on marriage and consanguinity, whose members are connected by common life, mutual assistance, moral and legal responsibility. This is a system of status-role relations between husband and wife, parents and children. As a social institution, it interacts with society, the state and other social institutions. That is, from the point of view of sociology, a family is a really and actually existing small group, regardless of how it arose, what procedures, ceremonies and rituals accompanied its emergence. Another important characteristic of the family is the continuity of generations. . Under the family, sociology understands such integrity, which is divided and restored in each generation.

From point of view economic, A family is a group of people who live together and share a household. But living together and running a joint household is not a sign of a family, but households. The household is often wider than the family in terms of its composition due to persons who maintain a common household with the family and even live together, but are not related to family members. Such persons may be educators, nannies, home teachers, employees, if they live in families of employers. These may also be those whom the family took in to support financially or because of the inability to serve themselves. A household is considered to be an individual, a family or several people living in a hostel or in a rented apartment and conducting a common household (food, housing care), but not necessarily related. Therefore, an addition is required: a family is a household, i.e. a group of people living together, united by kinship or property, as well as a common budget (joint farm).

Historical The aspect of the institution of the family is studied by historians, ethnographers and anthropologists who consider the family, primarily from the point of view of the typology of marriage, kinship, family types. The concepts of exogamy and endogamy, monogamy and polygyny, patriarchy and matrilineality came into sociology from these disciplines.

The history of the institution of the family in different cultures is a subject of study of cultural and social anthropology. These areas in science clarify the kinship system, types of marriage, roles and statuses in the family, family tree, rituals of betrothal, matchmaking, birth, death, naming, the position in society of widows and widowers, bachelors and divorced, orphans and illegitimate.

The concept of "marriage" is closely related to the concept of "family", and so closely that in everyday life they are often used as synonyms. However, if the family is an institution that regulates relations between spouses, parents and children and other relatives, then marriage, on the one hand, is secondary, since it is an institution that regulates relations only between a man and a woman, between the sexes, and on the other hand, the institution of marriage is primary. in relation to the family, because the family begins to exist only after the conclusion of marriage - a kind of "social contract, the obligation of spouses to comply with certain rules proposed and approved by society." The family is the result of marriage, and marriage is the gateway to the family. Different forms of marriage in history and today reflect both a certain level of development of the corresponding society, and historical, religious, national traditions. The result of this is different ways of creating a family, its different structure, differences in functions, etc.

Results of 2005-2011

The performance of any health care system is evaluated in terms of population health and demographic indicators, incl. by life expectancy (LE 1) and total mortality rate (ACS 2). Figure 1 shows the dynamics of the crude mortality rate (CDR) in the Russian Federation in the period from 1980 to 2011 and forecasts until 2020.

Rice. 1. Dynamics of ACS in the "old" and "new" countries of the European Union and the Russian Federation, forecast of ACS in the Russian Federation until 2020

This figure clearly shows that the implementation of the priority national project "Health" in the period 2005-2008. and a certain improvement in the socio-economic situation in Russia reduced the value of the ACS by 9% (from 16.1 to 14.6), which saved the lives of 450 thousand citizens of our country. Even a small annual investment in this project (10% of total government spending on health) in 4 years caused positive changes in the health status of the population.

In the period from 2008 to 2010, the value of TAC practically did not change, the decrease was only 3% (14.6 - 2008, 14.2 - 2009, 14.2 - 2010). This is due to the economic crisis of 2008-2009. and the stagnation of real, inflation-adjusted public health financing during this period. However, in 2011, due to the fact that the country's leadership decided to increase government spending on health care by 14% (or 220 billion rubles annually due to an increase in the rates of insurance contributions to the compulsory medical insurance system by 2%), the mortality rate in 2011 compared with 2010 decreased by 100 thousand people and the ACS decreased by 5% (from 14.2 to 13.5).

The most important lesson of these two periods - the increase in health care funding and the political will of the country's leaders made it possible to achieve a noticeable improvement in the demographic indicators in the country.

It should also be noted that as a result of the implementation of the programs of the Ministry of Health and Social Development of the Russian Federation in the period from 2008 to 2011, the following positive results were achieved in terms of other demographic indicators: life expectancy of citizens of the Russian Federation reached 70 years in 2011; for the first time in many years, an increase in the number of Russians to 143 million people was ensured; mortality from circulatory diseases decreased by 6.2%, from tuberculosis - by 7.4%, from road accidents - by 5.6%, from neoplasms - by 1%. Infant mortality also continues to decline, in 2011 this figure was 7.3 per 1,000 live births, and in 23 regions of the country, infant mortality is comparable to the level of EU countries (data from the report of the Minister of Health and Social Development “On the results of the work of the Ministry Health and Social Development of the Russian Federation in 2011 and Tasks for 2012”).

Figure 1 also shows the value of the GAC - 11.0, which is taken as the target in the Concept of long-term socio-economic development of the Russian Federation for the period up to 2020. If the GAC will decrease along the dotted line shown in Figure 1 (to the level of 11.0), then by 2020, 2.5 million lives of our citizens will be saved. However, this will require a much more intensive development of the health system and a more significant increase in its funding.

Unresolved health problems

Today, in the healthcare system of the Russian Federation, despite some achievements of the past years, serious problems have accumulated that will hinder the solution of the set tasks aimed at improving the health of the population, increasing the availability and improving the quality of medical care. Among them the main ones are:

1. Underfunding of the public health system by at least 1.5 times. There is no sufficient funding - there is no decent salary for medical personnel, there is no sufficient provision of the population with free medicines, there is no way to comply with modern standards of treatment and provide hospitals with modern equipment and consumables. Thus, in the Russian Federation in 2011, government spending on health care (including spending on the program of state guarantees, education, investment in infrastructure and sanitary and epidemiological well-being) amounted to 1.7 trillion rubles, or 4% in the share of GDP, which is 1 .5 times lower than the average in the "new" EU countries (6% of GDP). It should be noted that these countries have a GDP per capita per year close to that of the Russian Federation - about $20,000 PPP3, i.e. as economically developed as Russia.

More funding for health care allows these countries today to have a life expectancy of 76 years and an ADR of 11.0, i.e. even better indicators than those we want to achieve by 2020. From this it follows that further expansion of free medical care will require an increase in funding by 1.5 times, which is about 800 billion rubles. annually.

2. The second important problem is the shortage and suboptimal structure of medical personnel. If there are no doctors, there will be no affordable medical care. It is the doctor who provides the throughput of the health care network. Today, the provision of doctors in the Russian Federation per 1,000 population, excluding sanitary and epidemiological personnel and dentists, in the Russian Federation was 4.5, which is 1.5 times higher than the average in OECD4 countries, where it is 3.1 doctors per 1 thousand population. However, in the Russian Federation, the incidence and mortality of the population is 40-50% higher (see below) than in the OECD countries on average (accordingly, the need for medical care is also higher), so the assertions of some experts about an excess of doctors in Russia are unfounded.

Moreover, in the next 5 years, a significant shortage of medical personnel is predicted in the Russian Federation, associated with low wages for their work - it is 22% lower than the average wage in the Russian Federation. If we compare the level of remuneration for a doctor in the Russian Federation with the same level of remuneration for a doctor in the "new" EU countries, then in these countries a doctor receives 1.5-2.5 times more than the average salary in these countries.

The shortage will also be associated with a high proportion of doctors of retirement and pre-retirement age (about 50%) and a demographic failure. Thus, the number of school graduates in 2011 compared to 2003 decreased by 2 times and, as a result, in 5-6 years the number of university graduates will decrease by 2 times. Attention should also be paid to the extremely low level of remuneration of the teaching staff of medical and pharmaceutical universities, which, of course, does not stimulate an increase in the level of student education. Thus, the salaries of teachers of these universities do not exceed 15-20 thousand rubles. per month, while even secretaries and drivers in commercial firms have significantly higher earnings.

3. The third most important problem is the unsatisfactory qualification of medical personnel and, as a result, the low quality of medical care. No doctor is bad, but no qualified doctor is also bad. Insufficient qualification of medical personnel is manifested in unsatisfactory indicators of the quality of medical care in comparison with developed countries. For example, the survival rate of patients with breast cancer, the in-hospital mortality rate, the proportion of patients who received infectious complications in hospitals in the Russian Federation are 2 times higher than the average in OECD countries.

4. The fourth problem is the backlog of standards for the volume of medical care under the Program of State Guarantees (SGBP) of free medical care to the real needs of the population of the Russian Federation. It is this problem that causes queues in polyclinics, problems with the availability of medicines and high-tech medical care. For example, from 1999 to 2010, the standards for the volume of medical care for the SGBP did not change, and for a number of types of care they even decreased; at the same time, the incidence of the population (which determines the need for medical care) in the period from 1990 to 2010 5 times, and the proportion of the elderly population increased by 4%.

Our population is also insufficiently provided with free medicines on an outpatient basis, by prescription in polyclinics. Thus, in 2010, per capita spending on drugs from public sources in the Russian Federation was 5.6 times lower than in OECD countries (respectively, they amounted to $45 and $250 PPP), and 3 times lower than in the “new » EU countries, and this is at almost the same prices for medicines in our country and in them (Fig. 2) .

Figure 2. Total and government per capita spending on outpatient drugs in different countries

Moreover, today in the Russian Federation, mostly disabled people (about 13 million people) and a number of other few categories of citizens are entitled to free medicines, while in developed countries all the needy population is fully or partially provided with free medicines at the expense of state funds.

5. The fifth problem is the very low volume of high-tech medical care. For example, the number of revascularization operations on the heart (i.e., restoration of patency of the heart vessels), which make up 25% of the volume of quotas for high-tech medical care, is performed in the Russian Federation 5 times less than in the "new" EU countries, on average, hemodialysis procedures - 4 times less, the number of knee and hip arthroplasty operations - 6.5 times less (Fig. 3). Accordingly, the volume of these types of assistance within 5 years will need to be increased by at least 2-3 times.

Rice. 3. Number of knee and hip arthroplasty operations per 100,000 population

6. The sixth problem is the inefficient management of the industry at all levels. For example, in the Russian Federation there is no strategic planning and no responsibility of managers at all levels for achieving results (including annual reports) according to indicators adopted in developed countries, for example, indicators of the quality and safety of medical care, and performance efficiency. Poor management is manifested in the irrational distribution of public funds. Thus, the emphasis in state programs is placed on poorly controlled investment expenditures (construction and purchase of expensive equipment) that have a high risk of corrupt payments, instead of developing prevention and human resources. There is an inefficient use of equipment and beds. Also, cost-effective management tools are not used enough, such as competition on the basis of quality when purchasing medical care from health care providers, ratings of health facilities, and the use of economic incentives to achieve planned results.

External challenges to the healthcare system of the Russian Federation until 2020

When developing a health care program, demographic and socioeconomic challenges must be taken into account. The main demographic challenge that will require serious attention to the health of working-age citizens is the annual reduction of 1 million of the working-age population, or 9 million people by 2020.

One should also take into account the expected reduction in the birth rate due to a 15% decrease in the number of women of childbearing age by 2020; the factor of population aging (for example, the proportion of the population older than working age will increase by 5% by 2020). It is also necessary to note the unsatisfactory indicators of children's health (about 40% of children are born sick or fall ill during the neonatal period; in 1990 this figure was 17%) and the constant increase in the incidence of the population; respectively, and the need for medical care. For example, in 2010, 228 million cases of acute and chronic diseases were registered in the Russian Federation, which is 1.5 times more per 100,000 population than in 1990. The citizens of our country also lead an unhealthy lifestyle: the proportion of adult smokers and alcohol consumption per capita per year in Russia is almost 2 times higher than the average in developed countries.

It should also be taken into account that the most important socio-economic challenge is the dissatisfaction of the population with the quality and availability of free medical care (2/3 of those dissatisfied), which is associated both with insufficient funding for free medical care and the inability of the majority of the population to pay for this care on their own (55% population lives on monthly incomes of less than 15 thousand rubles).

New legal framework

The laws “On Compulsory Health Insurance in the Russian Federation” (Federal Law of November 29, 2010 No. 326-FZ) and “On the Basics of Protecting the Health of Citizens in the Russian Federation” (Federal Law of November 21, 2011 No. 323-FZ) will help solve health problems only partially. Thus, the Law “On Compulsory Medical Insurance in the Russian Federation” provides for serious positive norms:

Centralization of financing of the CHI system at the level of the Federal CHI Fund;

Rationing of tariffs for insurance premiums for the non-working population;

Changing the structure of the tariff for CHI - from 2013, the inclusion of expenses for the maintenance of the institution, as well as the inclusion of emergency medical care (2013) and high-tech care (2015) in the CHI system, i.e. organization of single-channel financing;

Increasing the responsibility of the regions for the provision of primary care;

Mandatory implementation of the procedures and standards of medical care within the framework of territorial CHI programs and the formation of criteria for the effectiveness of these programs.

At the same time, there are certain risk factors in the implementation of this law, which will require their solution in other federal laws or by-laws. For example, the centralization of funding with the subsequent redistribution of funds to the regions in the face of a general shortage of these funds may jeopardize the volume of healthcare financing in relatively wealthy subjects of the Russian Federation; consequently, doctors' salaries may suffer. Further, this law focuses on measures to expand the rights of the patient to choose a doctor and a medical organization without taking into account the territorial principle of attachment of the population, stages and levels of medical care to patients, which will entail additional costs in the system. The task is not to give freedom of choice to the patient, but to ensure the availability and quality of medical care in most medical organizations (and these organizations, as a rule, are located at the place of residence of the patient).

As for the Law “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, several positive norms should also be noted.

Transfer of powers to provide primary health care and emergency medical care from the municipal level to the level of the subject of the Russian Federation. This norm is dictated by the fact that most municipalities did not have enough funds to provide these types of medical care. "Poor" health care systems (as in the Russian Federation) should be centralized: it is easier to manage and control them.

Regulations on the provision of medical care according to the precinct-territorial principle, the use of a referral system. These provisions eliminate the risk of reducing the coordination of medical care to the population, introduced by the provisions of the draft law "On Compulsory Medical Insurance", which declare the patient's right to choose a doctor and medical organization.

The law also correctly resolves certain highly specialized health issues: in pediatric transplantation, in the treatment of orphan diseases, in the use of reproductive technologies, etc.

All these issues are important, but the primary goal of the country's main law on protecting the health of citizens is to consolidate the organizational and financial mechanisms for protecting and strengthening the health of all citizens of the Russian Federation, as well as for providing affordable and high-quality medical care to all sick people. Unfortunately, these issues are not properly reflected in the Law "On the fundamentals of protecting the health of citizens in the Russian Federation", it does not solve these problems. Moreover, this law will increase the discontent of the population (due to the risk of reducing the guarantees of free medical care), as well as medical workers, since it does not improve their situation.

Priorities and tasks for the development of health care until 2020

When forming priorities and tasks until 2020, it is necessary to take into account the goals for improving the health of the population set by the Government of the Russian Federation by this date. In accordance with the Concept for the Long-Term Socio-Economic Development of the Russian Federation for the period up to 2020, we must significantly improve the health indicators of the population, namely: increase the life expectancy of the population from the current 705 to 73 years and reduce the overall mortality rate from 13.5 cases to 1 thousand population to 11.0.