Organizational and Legal Aspects of Introducing New Organizational and Legal Forms in Healthcare

The dissertation studies the organizational and legal aspects of introducing new organizational and legal forms into healthcare. It examines international reform trends, forms of legal entities, healthcare systems, the features of state, municipal, and non-state organizations, and possible directions for changing the status of budgetary institutions. Separate sections address the autonomous institution, an analysis of risks and reform principles, and assessments by healthcare organizers and heads of medical organizations.

Relevance of the Study

In most countries, systems of public healthcare operate under severe financial constraints. Under these conditions, the principal task addressed at the state level is to identify the most effective ways to use the limited resources available and the organizational and legal forms of medical organizations in order to ensure the population receives the required volume of quality medical care. This problem is particularly acute during reforms affecting the social and economic aspects of societal organization.

The fifteen-year experience of large-scale reform of Russian healthcare has identified the main issues that must be taken into account when determining the further course of the reforms:

1. State guarantees of free medical care provided for by the legislation of the Russian Federation are declarative in nature and are not balanced by the funds allocated to financing the sector [62].

2. Deficiencies in the methods of financing and methods of payment for medical services used in healthcare.

3. Inefficient use of healthcare resources. Redundancy and disproportion in the network of preventive and therapeutic institutions.

4. Loss of systemic coherence and controllability of the sector despite the continued existence of management bodies at all levels; one reason for this is the unclear division of competences among the Russian Federation, its subjects, and local self-government bodies [20].

5. Insufficiency of the legislative framework and violations of the current legislation regulating the functioning of the healthcare system [11, 28, 49].

6. The contradictory status of healthcare institutions [97].

The widespread creation of state institutions in the sector — that is, structures entailing minimal economic responsibility for healthcare managers and absolute infantilism on their part as owners or managers of the principal state funds — is a direct path to shadow medical practice [6].

The development and implementation of economic methods of reforming healthcare constitutes the objective basis for optimizing medical care in contemporary conditions [84].

One of the principal tasks of reforming the healthcare system is to ensure the efficiency of its functioning. Two aspects — internal and external — can be distinguished in the concept of healthcare-system efficiency. The first refers to the ability to provide a specified set of services at minimal cost. The second reflects the ability to offer an optimal set of services that corresponds to the structure of societal consumption.

Addressing the problem of both external and internal efficiency in the healthcare system is impossible without changing the mechanism of interaction between payers and providers of medical services.

The prevailing institutional form in healthcare proves ineffective according to a number of parameters, whereas the forms of commercial organizations provided for by legislation cannot be fully used in healthcare because of the sector's specific characteristics [19].

Healthcare today faces this problem; possibilities for managing budgetary institutions are being analyzed from the standpoint of reasonable freedom in making independent managerial decisions and from the standpoint of forecasting external factors in the environment in which they exist [12].

The expansion of the economic autonomy of medical organizations is an urgent, fundamental issue in Russian healthcare. In the context of market relations developing in the country, where quality performance based on the economic efficiency of production and material incentives for employees is becoming the principal factor for service providers, it is becoming impossible to continue using only administrative methods in management [18].

Therefore, one of the most important directions for healthcare reform should be the creation of such a system of medical service providers within healthcare that would optimally combine features of state and private healthcare systems and of commercial and nonprofit organizations, use economic methods of organizing service provision, and simultaneously perform the functions assigned to the healthcare system by society.

Aim and Objectives of the Study

The aim of the present study is to conduct a comprehensive study of the organizational and legal aspects of the activities of medical organizations of various organizational and legal forms, identifying their advantages and disadvantages for addressing the task of providing the population with free medical care guaranteed by the state.

The following objectives were formulated to achieve this aim:

1. Study and analyze international experience in organizing the provision of medical care, taking into account the organizational and legal status of organizations engaged in medical activity.

2. Conduct a comparative legal analysis of the organizational and legal forms of legal entities (organizations) under the legislation of the Russian Federation.

3. Based on a study of the features of the functioning of state (municipal) institutions as the most common organizational and legal form in contemporary Russian healthcare, substantiate the need to change the organizational and legal status of preventive and therapeutic institutions.

4. Study various organizational and legal form options, taking into account the results of an analysis of the possibilities of using them as medical organizations when providing the population with free medical care guaranteed by the state.

5. Using the autonomous institution as an example, analyze the possible difficulties and consequences of changing the organizational and legal position of healthcare institutions.

6. Analyze the views of healthcare organizers on assessing the need for and prospects of various directions for reforming budgetary healthcare institutions and introducing new organizational and legal forms.

Scientific Novelty of the Work

For the first time, the work analyzes foreign experience in organizing healthcare from the standpoint of the economic and legal position of medical service providers.

For the first time, based on an analysis of the organizational and legal features of the functioning of healthcare institutions, the principal problems whose resolution is necessary during reforms aimed at changing the organizational and legal status of medical organizations are formulated.

For the first time, on the basis of an analysis of the features of the functioning of medical organizations of various organizational and legal forms within contemporary Russian healthcare, the work provides a scientific and practical justification for selecting the organizational and legal form of a medical organization.

For the first time, the possible difficulties and adverse consequences of introducing new organizational and legal forms into healthcare are analyzed; the principal principles for conducting the transformation process are determined, and provisions requiring clear legislative definition are formulated for decisions to change the organizational and legal status of budgetary healthcare institutions.

For the first time, the views of heads of healthcare institutions as principal participants in the process of changing the organizational and legal status of healthcare institutions are analyzed.

Theoretical and Practical Significance of the Work

The theoretical significance of the dissertation study lies in its demonstration of the need to change the organizational and legal status of healthcare institutions and in its comprehensive presentation of the advantages and disadvantages of possible variants of the organizational and legal forms of legal entities, taking into account the specific characteristics of the healthcare sector. The main provisions and conclusions of the dissertation may be used to further develop the theory of improving the organizational and legal status of healthcare institutions.

The practical significance of the dissertation study lies in the possibility of using its provisions and conclusions by federal state authorities, state authorities of the subjects of the Russian Federation, and local self-government bodies when making decisions on the reorganization of specific medical organizations. The dissertation materials may also be used in developing and adopting normative legal acts concerning fundamental issues in the activities of an autonomous institution.

The research materials may be used in the educational process of departments of higher medical educational institutions when training specialists in the specialty of 'Healthcare Organization and Public Health.' To increase legal literacy and the readiness of heads of medical organizations to change the organizational and legal status of the institutions they lead, proposals based on the research materials have been developed to amend and supplement the State Standard for Postgraduate Professional Training of Specialists with a Higher Medical Education in the Specialty of 'Healthcare Organization and Public Health' on issues of the legal support of the activities of healthcare organizations of various organizational and legal forms.

Presentation of the Research Results

The materials presented in the dissertation were reported on and discussed at the conference of the Department of the Fundamentals of Legislation in Healthcare of the Health Care Management Faculty of the Moscow Medical Academy named after I. M. Sechenov (MMA), Roszdrav, and at the interdepartmental conference of the Health Care Management Faculty of the Moscow Medical Academy named after I. M. Sechenov (MMA), Roszdrav.

The research materials were presented at:

The All-Russian Scientific and Practical Conference on Medical Law (September 13–14, 2006, Novosibirsk);

III All-Russian Congress (National Congress) on Medical Law (Russia, Moscow, May 30–31, 2007).

The results of the study are reflected in 8 scientific works published on the topic of the dissertation.

Provisions Put Forward for Defense

1. The existing problems in the functioning of state (municipal) budgetary healthcare institutions substantiate the need to change their organizational and legal status.

2. Alongside state (municipal) budgetary institutions, nonprofit organizational and legal forms — the autonomous institution and the autonomous nonprofit organization — are the most acceptable forms of medical organizations when providing the population with free medical care guaranteed by the state.

3. The existing system of professional postgraduate training of specialists in healthcare organization and public health requires additions concerning the legal support of the activities of healthcare organizations of various organizational and legal forms, with a view to increasing the readiness of heads to change the organizational and legal status of the institutions they lead.