Scientific Justification of the Directions for the Development of Rural Healthcare in a Subject of the Russian Federation (on the Example of the Novosibirsk Region)

The dissertation is devoted to the scientific justification of the directions for the development of rural healthcare on the example of the Novosibirsk Region. The work comprehensively examines the medico-social and demographic characteristics of the rural population, identifies the demand of the population for primary, inpatient, and specialized medical care, and determines the main problems of providing medical care in rural areas. The research was conducted under conditions of the reform of the healthcare system associated with the delineation of powers between the subject of the Russian Federation and municipal formations. On the basis of the conducted analysis, an optimal model of the system of medical care to the rural population was developed and scientifically substantiated, including feldsher-obstetric points, general medical practice, central district hospitals, and regional clinical hospitals. Mechanisms were proposed for improving the efficiency of the use of financial, staffing, and medical-technical resources of rural healthcare institutions, the organization of the diagnostic and treatment process, and the quality control of medical care. The implementation of the model in the practice of the Novosibirsk Region made it possible to improve the accessibility and quality of medical care to the rural population and contributed to the reduction of maternal, perinatal, and infant mortality.

Relevance of the Research

The problems of providing high-quality medical care to the rural population are associated with the uneven pattern of rural settlement; a sufficiently large radius of medical service, the specificity of conditions of agricultural labor and daily life in rural areas, and other factors. All these factors leave a distinct imprint on the nature of medical care (its volume and quality) provided to rural residents and require from healthcare management bodies the application of special organizational forms and methods of work.

Such a factor as the pattern of settlement (low population density, scattered settlements, and their remoteness from one another) exerts a substantial influence on the accessibility of medical care and constitutes an important condition for the formation of a network of rural healthcare institutions (Preobrazhenskaya V.S., 1991; Gadziev R.S., 1992; Filatov V.B. 1993, 1996; Shchenin V.A. 1997, 2000; Vodyanenko I.M., 2000, 2002; Lakuniya K.Yu., 2001; Mikhaylova Yu.V., Magnitsky V.A., 2002; Radulsha T.V., 2002; Reshetnikov A.V., 2003; Kuchenko V.Z., 2003; Rogozhnikov V.A., 2003; Khalfin R.A., 2003; Suslin S.A., 2004, 2005, 2006; Denisov I.N., 2005; Shchepnyov O.P., 2005; Galkin R.A., 2005; Snburina T.A., Badayev F.Ts., 2006; Tribunsky S.I., Kolyado V.B., Leshchenko V.A., Kolyado E.V., 2005; Chassin M., Kosecoff J., Part R., 1987; Baker M., 1988, et al.).

In rural areas, small-capacity institutions predominate, which are located far from one another. A shortage of sanitary transport, unsatisfactory condition of transport communications, and a large service radius of settlements limit medical workers in making home visits, and the majority of institutions are not equipped with telephones. For these reasons, serious difficulties arise in ensuring the continuity of the ambulatory and inpatient stages of care.

In rural institutions, there is a significant shortage of physicians of the primary link, while there is a surplus of specialist physicians; at the same time, there are insufficient numbers of physicians and middle-level medical workers trained to conduct targeted prevention. The professional qualifications of practicing medical personnel are often inadequate, and the level of diagnosis and treatment of patients is low. The coverage of preventive examinations in rural areas does not exceed 35–40% of the population.

All of this complicates the provision and outcomes of medical care to the rural population at the district level (Shchepnyov V.O., 2000; Vodyanenko I.M., 2000, 2002; Lakuniya K.Yu., 2001; Starshunov V.I., Kiselev A.S., 2001; Mikhaylova Yu.V., Magnitsky V.A., 2002; Vyalko A.I., 2002; Radulsha T.V., 2002; Rogozhnikov V.A., 2003; Suslin S.A., 2004, 2005, 2006; Denisov I.N., 2005; Shchepnyov O.P., 2005; Galkin R.A., 2005; Tribunsky S.I., Kolyado V.B., Leshchenko V.A., Kolyado E.V., 2005, et al.).

With the adoption of the Federal Law "On General Principles of the Organization of Legislative (Representative) and Executive Bodies of State Power of Subjects of the Russian Federation" (No. 131-FZ of 04.07.2003) and the Federal Law "On General Principles of the Organization of Local Self-Government in the Russian Federation" (No. 131-FZ of 06.10.2003), which delineated the powers between the level of a subject of the Russian Federation (state) and the level of municipal formations (municipal), the system of inter-budgetary financial relations within the subjects of the Russian Federation changed, which to an even greater extent actualized the problem of reforming rural healthcare.

In connection with the adoption of these laws, municipal formations were granted the powers to organize primary medical and sanitary care (PMSC), while the powers to provide specialized medical care were retained by the subjects of the Russian Federation and federal centers. Under conditions of a deficit of financial resources in municipal formations, this legal norm actually creates a threat to the financial self-sufficiency of municipal healthcare and does not exclude a reduction of the already low level of medical care provided to the rural population (Gerasimenko N.F., Aleksandrova O.Yu., 2005).

Methodological approaches to policy in the area of providing medical care to rural residents and to the planning of medical services aimed at improving accessibility and quality in the contemporary conditions of the delineation of powers between the subjects of the Russian Federation and municipal formations, new inter-budgetary relations, including financial ones, substantiate the necessity of a scientific search for new approaches to making organizational, managerial, and investment decisions, which determined the relevance, scientific novelty, and practical significance of the present research.

Goal of the Research

To develop and scientifically substantiate the main directions of development and the model of the healthcare system in rural areas of a subject of the Russian Federation on the example of the Novosibirsk Region.

Tasks of the Research

1. To provide a medico-social characterization and an assessment of the peculiarities of the health of the rural population.

2. To determine the demand for and satisfaction of the rural population with primary medical care, inpatient care, and specialized medical care.

3. To study the main problems of providing medical care to rural residents and to conduct an analysis of the staffing, resource, and medical-technical provision, as well as the activities of healthcare institutions in rural areas.

4. To substantiate the main directions for the development of healthcare in rural areas under conditions of the delineation of powers between the subject of the Russian Federation and municipal formations.

5. To develop and substantiate a model of the system of medical care to rural residents, including the organization of primary medical care on the principle of general medical practice and the mechanisms of its implementation, and to conduct an assessment of its effectiveness.

6. To develop and substantiate mechanisms for the optimization of the use by rural healthcare institutions of financial resources, medical-technical, staffing, and information-technical resources, the standardization of the diagnostic and treatment process, and to conduct an assessment of their effectiveness.

Scientific Novelty of the Research

The scientific novelty of the research consists in the fact that, under new socio-economic conditions, a comprehensive medico-social and demographic characterization of the rural population was provided, and the study of the lifestyle and state of health of rural residents was conducted.

The demand of the rural population for primary medical care, inpatient care, and specialized medical care was determined.

An assessment was given of the main problems of providing medical care to rural residents, the staffing, resource, medical-technical provision, and the activities of healthcare institutions in rural areas.

The research demonstrated that in the existing model of healthcare in rural areas — "feldsher-obstetric point (FOP) — rural physician ambulatory clinic (RPAC) — rural district hospital (RDH) — central district hospital (CDH) — regional clinical hospital (RCH)" — the RPAC and RDH operate insufficiently effectively.

It was shown that the optimal model of the system of medical care to residents of rural areas includes the FOP, general medical practice (GMP), organized on the basis of the RPAC and RDH, the CDH, and the RCH.

The main directions of development, the model of the healthcare system in rural areas, and the mechanisms for improving the efficiency of resource use under conditions of the delineation of powers between the subject of the Russian Federation and municipal formations were developed and scientifically substantiated.

Practical Significance of the Work

A model of the system of providing primary medical care, inpatient, specialized, emergency, and planned consultative care was developed and implemented, which made it possible to improve the quality, accessibility, and level of organization of medical care to rural residents.

The developed and implemented model of the system of medical care to rural residents and the mechanisms of its implementation under conditions of the delineation of powers between the subject of the Russian Federation and municipal formations made it possible to regulate the processes of staged provision of medical care to the rural population.

Mechanisms for the use of resources were developed that made it possible to improve the efficiency of the activities of rural healthcare institutions under conditions of the delineation of powers between the subject of the Russian Federation and municipal formations, as well as the accessibility and quality of medical care to the rural population.

The implementation in the Novosibirsk Region of the model of the system of medical care to residents of rural areas and the organizational technologies of its implementation demonstrated their effectiveness: a reduction in maternal, perinatal, and infant mortality, which are important indicators of the health of the population and of healthcare.

Introduction of the Results into Practice

The materials of the present research and the developed approaches to the organization of medical care to rural residents formed the basis of methodological recommendations and textbooks approved by the Methodological Council of the Novosibirsk State Medical University: "Main Directions for the Development of the System of Population Health Protection and Healthcare at the Territorial Level" (2003), "Organization of Medical Care to the Rural Population on the Principle of General Medical Practice" (2003), "Methodology for Calculating Indicators of the Activities of Healthcare Institutions Based on State Statistical Reporting Documentation" (2005).

The developed approaches to the formation of the healthcare system in rural areas were used in the preparation of the Program of Development and Structural-Functional Transformations in Healthcare for the Period Until 2008 (Decree of the Head of the Administration of the Novosibirsk Region No. 805 of 14.02.03, Order of the Administration of Healthcare of the Novosibirsk Region No. 66 of 10.02.03).

The recommendations developed on the basis of the dissertation are used in the practical work of healthcare management bodies and institutions of the Siberian Federal District (Novosibirsk, Kemerovo, and Omsk regions, and Altai Krai).

The results of the research are used in the educational-pedagogical process and in scientific-research work at the departments of social hygiene profile of the Novosibirsk and Altai State Medical Universities, the Novokuznetsk State Institute of Advanced Training of Physicians, and the Research Institute of the Siberian Branch of the Russian Academy of Medical Sciences.

Defense of the Work

The results of the research were presented at: the VII All-Russian Scientific and Practical Conference "Development of the System of Ensuring the Quality of Medical Care in Contemporary Conditions and Problems of Optimizing the Structure of Healthcare" (Moscow, 2002); the All-Russian Scientific and Practical Conference "Family Medicine in Russia at the Turn of the Centuries" (Moscow, 2002); the Interregional Scientific and Practical Conference "Public Health: Strategy for Development in the Regions of Siberia" (Novosibirsk, 2002); the Interregional Scientific and Practical Conference "The Role and Place of Regional (Krai) Clinical Hospitals in the System of Regional Healthcare" (Novosibirsk, 2004); the First International Scientific and Practical Conference "Public Health: Innovations in Economics, Management, Legal Aspects of Healthcare" (Novosibirsk, 2005).

Fifty-four scientific works were published on the topic of the dissertation, including 2 monographs; 35 works were published in scientific editions recommended by the Higher Attestation Commission of the Russian Federation for the publication of dissertation materials for the award of the academic degree of Doctor of Medical Sciences.

The dissertation was carried out in accordance with the plan of scientific-research work of the Department of Public Health and Healthcare with a Course in Economics of the Moscow Medical Academy named after I.M. Sechenov and is a fragment of the planned topic "Organizational-Economic and Socio-Psychological Technologies in the Protection of Public Health and Management of Healthcare" (state registration number 01.200.110512).

Main Propositions to Be Defended

1. The results of the medico-social characterization and the assessment of the peculiarities of the lifestyle and state of health of the rural population constituted the basis for determining the demand of the rural population for primary medical care, inpatient care, and specialized medical care under conditions of the delineation of powers in the healthcare system between the subject of the Russian Federation and municipal formations.

2. The conducted research showed that priority directions in the development and in ensuring financial, staffing, and material resources in the healthcare system of rural areas are general medical practice, the FOP, the CDH, and the RCH.

3. The developed, scientifically substantiated, and implemented in the Novosibirsk Region model of the healthcare system in rural areas (FOP — GMP — CDH — RCH) makes it possible to improve the accessibility and quality of medical care to rural residents at the level of rural municipal formations and at the level of the subject of the Russian Federation on the basis of the optimization of organizational technologies and resource provision.

4. The developed, scientifically substantiated, and implemented organizational technologies based on the standardization of the diagnostic and treatment process make it possible to improve the efficiency of the use of resources in rural healthcare institutions.