Scientific Foundations for the Optimization of Resource Provision Management in Municipal Healthcare

The dissertation is devoted to the scientific substantiation of the optimization of resource provision management in municipal healthcare. The work comprehensively examines the problems of the formation of territorial programs of state guarantees of free medical care, the comparative analysis of recommended, guaranteed, and actual volumes of medical care, and the financial provision of municipal healthcare systems. Strategies and tactical mechanisms for enhancing the resource base, including additional sources of financing, are investigated, and a model for optimizing resource provision management at the municipal level is developed.

Relevance of the Research. The implementation of state policy, which has determined the modern development of the Russian Federation in recent years, has brought about serious changes in all spheres of life. Changes in the powers of governance find their reflection in the healthcare system, which, precisely at the municipal level, serves as the most important instrument for the implementation of state policy in the social sphere, determining the potential of human life, for the well-being of which the state itself functions (Annual Address of the President of the Russian Federation, 2005).

The totality of state obligations in the sphere of healthcare is primarily expressed in the form of state guarantees of free medical care for the population. Despite the constant growth of budgetary and insurance financing for the realization of these guarantees, a deficit of necessary funds nevertheless exists, which brings to the forefront the problem of the balance of obligations of the authorities and their financial provision (Grinenko A.Ya., Grinenko O.A., 2004). Undoubtedly, the ultimate solution is determined by the capabilities of the federal and regional budget, but the main potential is formed at the first level of healthcare — in the municipal system.

Under modern conditions, insufficient resource provision gives rise to a significant number of specific problems: from preserving the accessibility of medical care (Shchepin O.P., 2004) to the efficiency of management (Starodubov V.I., Tikhomirov A.V., 2004), the search for solutions to which, accordingly, becomes quite relevant, and precisely within the basic unit of the system — municipal healthcare.

The optimization of resource provision, primarily for the purpose of implementing state guarantee programs, can only be comprehensive, since all aspects of the problem are interrelated: on the one hand, this is the search for ways to increase the volume of funds flowing into the system, including through additional sources (Trishin V.M., Vishnyakov N.I., 2004), and on the other — the determination of pathways for increasing the effectiveness of medical care through its reform (Denisov I.N. et al., 2004; Filatov V.N., 2005), which makes it possible to enhance the efficiency of use of necessary resources and their inflow.

The existence of published research results on various aspects of the optimization of the activity of medical institutions, unfortunately, still leaves questions already at the stage of the very development of territorial programs of state guarantees in terms of the sufficiency of volumes of care and their financing, their correspondence to needs; at the implementation stage — regarding the choice of methods for attracting additional funds, the rationality of their use for the formation of effective material and human resources, as well as methods of management of provision as a whole.

To date, this problem of resource provision of healthcare in municipal formations has not been studied in such a systemic form, although its model character is sufficiently obvious and the methods of its solution may be useful for reducing the acuity of analogous problems already at the city and regional levels, which in general determines the relevance of this research.

The goal of the research is to identify and substantiate pathways, means, and methods for optimizing the management of resource capabilities of municipal healthcare in ensuring the population with accessible and adequate medical care.

The tasks of the research for achieving this goal were determined as follows:

1. to study the dynamics of the specifics of the need for and provision of medical care to the population in the municipal healthcare system;

2. to conduct a comparative analysis of recommended, guaranteed, and actual volumes of medical care in accordance with the territorial program of state guarantees of free medical care, the state of health of the population, and the actual conditions of functioning of the healthcare system;

3. to determine the possibilities of financial and economic provision of necessary volumes of medical care in accordance with the structure of medical care provision and sources of its financing;

4. to carry out an analysis of the use of funds for the actual resource provision of the municipal healthcare system corresponding to the existing types of revenues and expenditures;

5. to develop a model for optimizing the management of resource provision of the healthcare system at the municipal level under modern conditions;

6. to assess the effectiveness of the developed complex of optimization measures based on the results of the activity of the municipal healthcare system.

Scientific Novelty of the Research. For the first time, a study was conducted of the correspondence of volume norms in the formation of territorial programs of state guarantees for the provision of free medical care to the population and the general actual need, and objective factors conditioning the possibility of inadequacy of planning were identified. For the first time, an assessment was made of the role of various sources of financing both in relation to programs of free care for the population and for the activity of the healthcare system at the municipal level, with the determination of the capabilities of each of them. The strategic place and significance of sources of additional financing were studied, and tools for the tactics of their development were developed. Rational methods for the development and use of the resources of the healthcare system were identified. Managerial mechanisms for the improvement of medical care and pathways for increasing its efficiency based on the optimization of resource provision were determined.

Scientific and Practical Significance of the Work. On the basis of an analysis of the ratio of the calculated, approved, and actual programs of state guarantees of free medical care, problems arising in their development were identified and corresponding methods for their solution were proposed. The results of the research made it possible to substantiate and recommend to healthcare management bodies expedient changes in the forms of tariff payment capable of ensuring the simplification of planning and increasing the targeted effectiveness of the use of budgetary appropriations and insurance funds for the provision of free care to the population. The methods for improving resource provision identified in the research, based on the structural and functional unity of the elements of the healthcare system, the stimulation of personnel, and adequate investment in material and technical equipment, make it possible to expand the possibilities of medical care and actually improve its effectiveness. The developed and practically tested complex of measures for managing resource provision represents a comprehensive model for optimizing the provision of medical care, accessible for application in any medical institutions and their system.

Implementation in Healthcare Practice. The materials of the dissertation research have been introduced into the work of a number of municipal healthcare institutions of the Leningrad Oblast, including the Kirishi Central District Hospital, the Tikhvin Central District Hospital, the Mariinsky Hospital of Saint Petersburg, into the practice of the Committee on Healthcare of the Leningrad Oblast, the activity of the Committee on Healthcare of Saint Petersburg, are used by the Administration of Healthcare of the Vologda Oblast, and have been included in the educational process of the Department of Social Hygiene, Economics, and Healthcare Management of the State Educational Institution of Additional Professional Education "Saint Petersburg Medical Academy of Postgraduate Education" of the Federal Agency for Healthcare and Social Development.

Defense of the Work. The results of the research and its main provisions were presented and discussed at meetings of the problem commission of SPbMAPO "Hygiene, Healthcare Organization, and Medical Education" (Saint Petersburg, 2005, 2006), at the II Congress of Chief Physicians of Curative-Preventive Institutions and Centers of the State Sanitary-Epidemiological Surveillance of the Northwestern Russian Federation (Saint Petersburg, 2003), at a scientific conference dedicated to the 200th anniversary of the Mariinsky Hospital (Saint Petersburg, 2003), at the I International Scientific and Practical Conference "Public Health: Innovative Economics, Law, and Management in Healthcare" (Novosibirsk, 2005), and were presented at conferences of the Russian-Swedish International School of Public Health (Saint Petersburg, 2003, 2004), the Russian-Swedish-Estonian meeting on problems of healthcare financing (Tartu, Estonia, 2005).

Seven works have been published on the topic of the dissertation.

The author's contribution consists in the planning, organization, and conduct of research on all sections, in the formulation of goals and objectives, in determining the nature of the material and the choice of methodologies, in the preparation of carriers and the accumulation of primary data and material, in the study of publications, in the conduct of information analysis, and in the formatting of research results. Assistance in conducting separate statistical and economic research was provided by employees of the Committee on Healthcare of the Leningrad Oblast. The author's share in the accumulation of material is 100%, in statistical data processing — 95%, in information analysis and formation of results — 100%.

Main Propositions to be Defended:

1. Results of the analysis of the possibilities of the calculated, approved, and actual programs of state guarantees of free medical care and their financial provision in the context of the needs of the territory, and pathways for increasing their adequacy;

2. Optimization of the formation of revenues and expenditures of the healthcare system in financial management through the growth of resource provision of medical care;

3. Strategy for achieving aggregate sufficiency of revenues and tactical means for the development of paid medical services for the implementation of programs of free medical care for the population;

4. Substantiation of a comprehensive model for optimizing the management of resource provision and the effectiveness of its application in the practice of functioning of the municipal healthcare system for expanding the possibilities of providing care to the population.

Structure and Volume of the Dissertation. The dissertation consists of an introduction, a literature review, a description of materials and research methodology, four chapters presenting the results of the author's own research, a conclusion, propositions, practical recommendations, a list of references including 256 sources, including 114 foreign publications, and appendices. The dissertation is presented across 195 pages of typed text and contains 44 tables and 2 figures.