The State of Organization and Approaches to Improving the Emergency Medical Services System of Dushanbe City under Contemporary Socio-Economic Conditions

The dissertation is devoted to a comprehensive investigation of the state, history of development, and prospects for improvement of the Emergency Medical Services (EMS) system of Dushanbe city under the conditions of the socio-economic transition period. In the work, on the basis of the analysis of literary sources and the author's own socio-hygienic research, a comprehensive evaluation is given of the organization, material and technical support, personnel potential, and the quality of emergency medical care provision to the population at the pre-hospital stage for the periods prior to and following the attainment of State Independence of the Republic of Tajikistan. The research identifies shortcomings in the organization and management of the EMS system and substantiates scientifically grounded approaches to increasing its efficiency.

Relevance of the Research. Social and economic instability in the Republic of Tajikistan has had a sufficiently negative impact on the state of the health care system, in general, and the Emergency Medical Services (EMS) system, in particular. At the same time, the low efficiency of the health care system was exacerbated by the disruption of economic ties, the decline in production, financial and other difficulties, which contributed to the recognition of the urgent necessity of conducting reforms in the health care sector and, in particular, the Emergency Medical Services [9]. The Emergency Medical Services at the current stage of societal development constitute a socially significant type of medical care. Its organization and structure, throughout the world, are to a considerable extent determined by the general level of health care development and are, at the same time, inseparably linked with its reforming [129]. According to WHO data, approximately 20% of people worldwide die due to the absence of qualified medical care at the pre-hospital stage, which defines the enhanced role of emergency medical services for the population within the health care system [1, 46, 51]. The existing achievements in the provision of this type of medical care are insignificant, mainly due to extensive development (growth in the number of mobile brigades, the number of physicians and mid-level medical personnel, and the strengthening of material and technical support). Further improvement of the organization, management, optimization of the structure, and provision of EMS to the population of Dushanbe city require the identification and realization of unused resources based on the enhancement of the quality of medical care and the intensification of work, the revision and creation of new regulatory standards for the functioning of the EMS system.

Government Resolutions of the Republic of Tajikistan adopted (the "Concept of the Health Care Reform of the Republic of Tajikistan" dated March 4, 2002, No. 94; the "Strategy of the Republic of Tajikistan on the Protection of Public Health for the Period Until 2010" dated November 5, 2002, No. 436; "On the Approval of the Strategy for Financing the Health Care Sector of the Republic of Tajikistan for 2005-2015," dated May 10, 2005, No. 171; the "Strategy of the Republic of Tajikistan on the Restructuring of the Hospital Service for the Period 2006-2010" dated September 7, 2006, No. 407) are directed toward the policy of conducting reforms in the country's health care sector with the aim of maintaining and improving the health of the population. At the same time, the established system of medical care provision to the population does not ensure the necessary efficiency, being, moreover, high-cost. According to numerous authors, in most cases the EMS system performs functions inherent to neither it nor its intended purpose, substituting for the functions of the outpatient-polyclinic service in providing home-based assistance and patient transportation [70]. At the same time, a significant proportion of EMS brigade dispatches to patients requiring urgent support of vital functions and at the scenes of incidents are carried out untimely.

The analysis of literary sources based on research conducted in our republic revealed their scarcity on this topic, mainly concerning the medical aspects of the hospital stage of the EMS system. The organizational aspect of the question was reflected far less frequently, due to fundamental differences in the principles of approach to the construction of the medical care provision system, in particular at the pre-hospital stage, which in foreign countries is entirely different [24]. Despite a number of substantial successes in the field of EMS provision at the pre-hospital stage, research dedicated to the improvement of the work of the emergency medical services system in specific regional conditions is rare. The above determines the relevance of the present research.

Goal of the Research. To develop scientifically grounded proposals for improving the organization of management, optimizing the structure, and providing emergency medical services to the population of a large city.

Tasks of the Research. 1. To study the history of the organization and activities of the Emergency Medical Services system in Dushanbe city during the various periods of its development.

2. To evaluate the organizational-methodological activities of the City Clinical Base of Emergency Medical Services (GKBB SMP) of Dushanbe city at the pre-hospital stage prior to and following the transition period.

3. To conduct an analysis of the quality and volume of medical care provided by the GKBB SMP of Dushanbe city at the pre-hospital stage prior to and following the transition period.

4. To evaluate the effectiveness of the activities of the GKBB SMP of Dushanbe city prior to and during the stages of the transition period.

5. On the basis of the obtained data, to develop approaches to improving the system of emergency medical services provision to the population of Dushanbe city at the pre-hospital stage.

Scientific Novelty. For the first time in the Republic of Tajikistan, on the basis of the analysis of literary and historical reference materials, as well as the author's own results of a socio-hygienic research, a comprehensive evaluation was given of the history of the organization, formation, and development of the EMS system of Dushanbe city prior to and following the attainment of State Independence, taking into account the specifics of regional conditions. The analysis of certain aspects of the organizational-methodological and therapeutic activities prior to and during the transition period made it possible, for the first time, to evaluate the state of the material and technical base, the personnel potential, and the quality of EMS provided at the pre-hospital stage, taking into account the qualifications of specialists. For the first time, an in-depth analysis of the quantitative and qualitative indicators of the EMS system activities of Dushanbe city was conducted prior to and following the attainment of State Independence (1980-1991; 1992-2006).

The obtained data revealed shortcomings and certain achievements in its organization and management, as well as the features of its development, requiring the conduct of measures directed toward the improvement of its structural-functional organization. For the first time, at the regional level, an assessment was conducted of the degree of population satisfaction with the quality of EMS provided. Taking into account the obtained results, scientifically grounded approaches to the improvement of EMS for the population of such a large city as Dushanbe were developed for the first time.

Practical Significance. The results of the research made it possible to give an objective assessment of the state of emergency medical care for the residents of Dushanbe city at the pre-hospital stage. Shortcomings and certain achievements in the organization of the GKBB SMP of Dushanbe were identified, and the indicators of its activities were evaluated. Optimal approaches to increasing the efficiency of the work of mobile emergency medical services brigades of various profiles were proposed. The results of the author's own research were used in the development of methodological recommendations "Standards for the Volume and Quality of Emergency and Urgent Medical Care of the Emergency Medical Services Station of Dushanbe City" (2005) and "Temporary Normative Staffing of Medical and Pharmaceutical Workers of the Station (Division) of Emergency Medical Services" (2005), regulating the activities of the EMS system at the pre-hospital stage. The results of the conducted sociological research of patient opinions also make it possible to judge about the quality of emergency medical services provided at the pre-hospital stage.

Basic Propositions of the Dissertation, to be Defended.

1. The imperfection of the organization and management of the Emergency Medical Services system of Dushanbe city is noted.

2. There is a necessity of revising the existing legislative and regulatory aspects governing the activities of the Emergency Medical Services system in the Republic of Tajikistan.

3. Contemporary trends in the utilization of emergency medical services by the population are presented, and the results of the analysis of the activities of the GKBB SMP of Dushanbe city at the pre-hospital stage are reported.

4. Systems of organizational measures for the improvement of the Emergency Medical Services system for the population are substantiated.

Implementation of the Results in Practice. The results of the research were implemented in the practical activities of the GKBB SMP of Dushanbe city, as well as in the educational process of the Department of Public Health, Economics, Management (Managerial Skills) in Health Care with a course in Medical Statistics of the Tajik Institute of Postgraduate Training of Medical Personnel (TIPPMK).

Presentation of the Work. The materials of the dissertation were discussed at a republican scientific-practical conference with international participation (Tursonzade, 2007), a city scientific-practical conference of surgeons with international participation (Dushanbe, 2007), and a meeting of the expert-problem commission on therapeutic and public disciplines of TIPPMK (Dushanbe, 2007).

Publications. Four works on the topic of the dissertation have been published, of which one is in a journal.

Structure of the Dissertation. The dissertation is presented across 150 pages and consists of an introduction, a literature review, materials and methods, a chapter of own observations, a conclusion, conclusions, practical recommendations, and a list of references. The work is illustrated by 16 tables, 6 figures, and 1 scheme. The bibliographic reference list includes 229 sources, of which 51 are foreign.