The concept of the development of St.Petersburg health care 1998-2003

The concept of the development of St.Petersburg (further Concept) is a combination of juridical, organizational and economical means which are dedicated to the realization of state policy in health care in St.Petersburg.

The concept was developed according to the order of the Governor of St.Petersburg (list of orders N 19 from 25.08.97) by Committee of Health Care with participation of Commission of Health Care of City's Parliament, trade union of medical employee representatives, Committee on science and higher education , specialists of St.Petersburg Pavlov State Medical University, Medical Academy of Postgraduate Studies, leading educational and scientific institutes and specialists of St.Petersburg Bureau of Medical Statistics, district health committees, territorial fund of obligatory medical insurance, association of medical insurance companies and non-governmental medical organizations.

Concept was developed according to the Constitution of Russian Federation and laws of Russian Federation and St.Petersburg concerning health care according to the concept of development of health care and medical science in Russian Federation, developed by Ministry of Health of Russian Federation and adopted by Order of Russian Government N 1387 from 05.11.97.

General ideas of Concept were discussed and agreed upon on II all-city conference "Medicine and Management: in search of common solution", held on July, 29 1997, on meeting of Medical Council of St.Petersburg Governor on September, 16 197 and discussed among medical specialists of the city.

Concept is dedicated to coordination of work of representative and executive authorities, industry and organizations in health care development in St.Petersburg and rational use of resources.

Main ideas of the Concept should be included in city programs and plans of the St.Petersburg development.

On every stage of the project realization and due to changes of socio-economical situation and juridical basis the Government of St.Petersburg can introduce changes into Concept.

1. Demographical situation , health indicators and health conditions in St.Petersburg

1.1 Demographical situation and morbidity

1.1.1 Demographic peculiarities of St.Petersburg

The population of St.-Petersburg was 4 778 900 by 1997. By the beginning of 1997 the population reduced every year. The average reduction of the population beginning with 1991 is 1% per year. Because of the high level of mortality the expected average length of human life after the birth in St.-Petersburg has reduced from 70,5 to 68,4 for the last ten years. In spite of some stabilization of indicators of mortality and birth rate in 1994-1996 the demographical prognosis is unfavourable. The coefficient of demographical pressure on whole able-bodied population of St.-Petersburg is raising. The major reason of decrease in St.Petersburg population is excess mortality (2.15 times) over birth rate.

Most important factor as decrease in birth rate. Mortality peaking in 1993 (17.4 per 1000) now started to decrease. From 1994 population decrease started to level off.

The city contains many objects connected with radiation, chemical and fire danger could create situation with medical consequences.

A disturbing tendency of the last ten years is increase in mortality from the work age people due to increase in accidental and violent deaths incuding criminal, sharp increase in alcohol consumption, tobacco, desocialization of large population groups living beyond poverty line.

The results of major demographic processes are:

increase in number of elderly

decrease in regeneration potential due to decrease in birth rates and proportion of children and adolescents

1.1.2 Morbidity of St.Petersburg population

Socioeconimic and demographic tendencies, unfavorable ecological situation resulted in changes in morbidity. Morbidity is high.

In the morbidity structure most important are diseases of cardiovascular system (20.7%), diseases of pulmonary system (19.7%), traumas and poisoning (13.1%).

The major tendencies are high level and tendency to increase in social significant disease rate (comparing with 1991): tuberculosis increased in 1.7 times, drug abuse 2 ties, lues 11.5 times, trauma 3 times, oncological disorder 1.2 times. The cardiovascular morbidity is also increasing.

In the structure of children morbidity most important are: pulmonary diseases (50.3%), nervous system disorders (9.4%), infection diseases (8.7%) and disorders of digestive tract (8%).

The analysis of morbidity of children shows serious increase in neoplasia comparing with 1991 (among children 1.7 times, among adolescents 5.4 times) increase in malformation rates.

Among others most widespread type of pathology both among adults and children are caries and disorders of oral cavity (90% of population). It is important to note that rate of dental disorders are 7-10% higher than in other parts of Russia.

1.1.3 Needs asessment of health care usage by St.Petersburg population.

On the base of the previous demographical and medical features, which are stable for the last ten years, we can prognosticate the following:

the reduction of needs in beds fond of service of motherhood and obstetrics with the necessity of rising its quality level;

- the reduction of needs of stationary places in the pediatrical service with the necessity of the rising its quality level;

- the rising of needs in emergency health care, mainly- surgical, traumatological, reanimational care;

- the rising of the needs in oncological help, including the early diagnostics and the help to the incurable patients;

- the rising of needs in geriartrical help, and the developing the system of care and medical-social adaptation;

- the necessity in developing and realization interdepartmental programs for the purposes of preventive treatment of social-important illnesses: tuberculosis, STD, drug abuse, toxicomania, alcoholism, etc.

1.2 The state of the health care system in St.Petersburg

In the city of St.Petersburg there are many medical organizations responsible to federal and city authorities as well as private organizations. They include 393 in- and outpatient departments responsible to Ministry of Health, from them directly subjected to Committee of Health care 81 in-patient and 260 outpatient departments, 8 ambulance stations and other.

For the period of 1991-1996 the number of stationary patients has reduced on 8%. For the last 5 years the number of beds has been reduced on 14.5%, the average using of a bed is 286,1 days a year instead 340 planned days.Average length of hospital stay practically does not changed from 1991 and now is 18 days.

The members of the medicians of all different specialities in treatment and prophylactics organization of the Ministry Health and Care system for the last five years stays unchangeable- about 31 000, the number of lower medical workers- 48 700 (reduced in 1,5 times - 2600). Physicians density per population increased during 5 years in 1.06 times and now is 66.5 per 10 thousand which is more than 2 times higher than in developed countries. In the same times ratio of nurses to physicians is 1.6:1 (WHO recommended figures 4:1).

From 1992 significant changes took place in health care: transition to obligatory medical insurance took place, network of non-state owned medical organizations is developing. The transition to compusatory medial insurance allowed to sustain volume and quality of medical care.

In the same time constant decrease in real financing of medicine both from city and federal budget and compulsory meical insurance means. In the city budget structure percent spent on health care decreased from 23% in 1987 to 10.7% in 1996. Almost ceased financing of development of health care institutions, preventive measures, renovation, purchasing equipment, other direct costs.

It should be mentioned that with a normal satisfactory percent of depriciation of main fonds of state health care organizations, that is something more than 30% today, most of the stationary buildings have dpriciation more than 60% (47 of them were built in the 19th century). Of 290 buildings 12 are in a very bad condition, 19 of them need the reconstruction, and 78 need the major repairs. There no systems of security and fire-alarms in the most stationary buildings of the city.

In the condition of insufficient financing all drawbacks of existing system are clearly seen. Non rational use of all resources decrease effectiveness of development of health care and as result, quality of health care.

Existing system and principles of health care management is not correspond to the modern requests.

Existing juridical base is not complete.

The system of obligatory medical insurance stopped its development.

No mechanisms of effective organization of health care are not created, federally responsible University Clinics and Scientific Institutes are slowly included into the system of obligatory medical insurance.

In the structure of heath care it is necessary to transfer accent to outpatient and home treatment, decrease and restructuring of hospitals, development of more economical technologies, increase cooperation between in- and outpatient parts of medical care. Work of medical organization still oriented to crude data but not quality care indicators.

Not enough work is conducted with staff, especially managers in health care.

Scientific and industrial potential of St.Petersburg is not used properly. Research work is weakly oriented to the practical situation.

The activity of existing professional medical associations is coordinated properly, sometimes conflicting. They are not always dedicated to increase professionality and defense of interest of medical professionals.

2. Goal and major tasks

The goal of the Concept realization is creation of legislative, economical and organizational mechanisms of optimal use of health care resources for increase in quality of medical and preventive care in St.Petersburg during reform of health care in St.Petersburg.

The result of the concept realization should be secure state garanties of satisfaction of needs of population of St.Petersburg in accessible medical and pharmaceutical care, increase in effectiveness of the health care system in St.Petersburg, stabilization (and in future improvement) of health indicators and decrease in preventable losses of health.

Major tasks of concept:

development of unified principles of development of mechanisms of governmental management and financing of health care in forms corresponding to the contemporary legislative and economical demands

development of reginal legislative base of Health care in St.Petersburg

transition from cost-incurred system of financing to th effective ditribution of financiall, human and materia resources

development of system of state control of movement of financial means dedicated to health care

preparation and implementation of structural reform in major parts of health care - outpatient, ambulance/emergency, inpatient care, including:

reorganization of ambulance/emergency care with transfer of some ambulance stations (in case of evidence-based support) to the hospitals, giving emergency care

further reform of primary care with change to the general practice physician system

rational changes and decrease in number of hospital beds in city, organization of emergency department in hospitals, outpatient consultative departments, development of nursing beds, hospices, gerontology units

further development of the system of obligatory medical insurance, system of quality assessment and control in health care, balancing relationship between medical organizations and insurance companies

regulation of relationships with federal authorities on the questions of property ownership, planning and financing of activity of medical organizations responsible to federal authorities

development of socially important health services: narcological, infection control, psychiatric, skin disorders/STD, antituberculosis

development of preventive services for mother and children

creation of rational and economical system of privileged drug provision, state control of all stages of drug distribution

increase in medical staff qualification, including heads of medical organizations by developing the system of postgraduate training, certification and attestation

strengthening the material basis of medical organization, including purchasing modern medical equipment

support of development medical, pharmaceutical and preventive non state-owned organizations the work of which will be dedicated to the solving most important tasks of state policy in health care

development of unified approach to health care informatization, active utilization of informational technologies for the tasks of management, effective use of resources and control of financial relationships

development of professional medical associations

development of social protection of medical staff: increase in salary, over the level fixed by Federal Government; improvement of living conditions, etc.

preventive work, especially with socially important diseases, healthy life style propaganda, increase in interest of citizens in supporting their health, including economical motivation.

3. Improvement in health care management

In 1992-1997 the situation in the health care management has changed principally.

The legal and economical status of health care authorities and medical organizations has changed. The spectrum of responsibilities of Health care Committee has decreased. Medical organizations has obtained significant degree of financial and legal independence. As the results the authorities began to lose control over situation in the health care system, the interaction between Health Care Committee and district health authorities weakened.

United in the past system of organization and financing of medical care was divided between systems of health care and medical insurance. But basis for joint control over these two systems was not created.

In the Concept framework it is planned to undertake following measures to improve system of health care management:

reorganization of health care committee and strengthening of its staff structure
development and implementation of model structure and function of territorial (district) health care authority organs
development of mechanisms of coordination of activity and orders of Health Committee and Territorial fund of Compulsory medical insurance, creation of joint working group
development and implementation of new reporting forms, which will place more emphasis on effective usage of resources, adequacy of existing facility to the needs of population
development and implementation of current and perspective planning according to the different levels:

- Committee of Health Care

- district (territorial) health authorities

- individual medical services

- Chief Health Care Authority

development and implementation of the new programs of preparation of managers with inclusion in curriculum basics of commercial and work legislation, economy, accounting, taxation, management and marketing
creation of data base "Health Care Managers in St.Petersburg"
ensuring coordination of district health authorities with medical, educational and pharmaceutical organizations
reorganization of the network of methodological offices into the representation offices of Heath Care Committee with strengthening methodological, control and information-analytical functions
coordination of research work in the interest of city basing on the unified program of research in health are; active and broad participation of prominent scientists and researcher in the resolving most important tasks of health care development
development of new public institutes of management subjected to Administration of St.Petersburg and Committee of Health Care:
- - participation in activity of Medical Council of St.Petersburg Governor
- - creation of Scientific Council of Heath Care Committee, development and agreement on Statement on Scientific Council and its members
- - reorganization of College of Health Care Committee with improving perspective planning functions
- - creation of Chief specialists Council under Health Care Committee, development and agreement on Statement on Council and its members
development of working groups for interadministrative management and coordination on:
- - financing and property (with Financial Committee and City Property Committee)
- - activity of higher educational institutes and scientific research institutes (with Science and Higher School Committee)
- - according to complex social-medical programs: development of geriatric and antituberculosis services, prevention of alcohol and drug abuse, prevention of STD and HIV (with Committees on Labour and Social protection, Education, Family, children and adolescents, Administration of Interior, State sanitation control)
creation of expert groups for participation in development of competitions on development and implementations of new technologies, centralized purchasing of drugs and medical equipment, reconstruction
organization of the control over results and effectiveness of decisions

It is also necessary to coordinate activity with

State Sanitation Control
Medical and Educational institutes of federal and ministerial responsibilities on the territory of St.Petersburg
non-state owned medical institutes
Health care system of Leningrad oblast
Health Care system of North-West region of Russia basing on the "concept of development and interaction of health care systems of North-West region of Russia"
federal found of obligatory medical insurance - on increase in participation of St.Petersburg in the programs of Federal Found, including modernization of leading medical technologies, connected with endoscopy, equipping operation wards and reanimation wards with contemporary monitoring equipment, equipping outpatient departments with express analyzers implementation of modern dentistry technologies

4. Improving quality of medical care

In the present time questions of quality control in medical care are among most important for our health care. Old system of control in contemporary condition ceased to be effective due to formation of several financing systems in health care and a new quality control system still not corresponds to contemporary demands, which stems from not sufficient legal base.

Last years are characterized by appearance of many subjects in this system who are responsible for quality control. But there are no responsibility division which results in function overlap. Existing mechanisms should be analyzed and changed. Moreover, not all programs for quality improvement in St.Petersburg had scientific background and some of the are questionable. From the other side St.Petersburg have experience in quality control, analysis of which can help in creation of unified standards of medical care and make these standards federal.

Concept of the development of health care quality based on:

creation of regional system of health car quality management
improving legislative base of St.Petersburg with the aim of increasing quality of care
improving mechanisms of structural quality of medical care mostly basing on incentives and technological quality basing on disincentives
optimization of quality control through resource management
formation of scientifically sound means of the control of components of medical quality control

5. Economics and health care finance

The finance of the health care system today is characterized by two tendency: insufficient finance and ineffective using of funds. The debts of medical and prophilactical organization to city monopolists such as Lenenergo, Lentech, Vodocanal, PPN, etc. is rising. There are no effective economical ways for increasing effectiveness of medical care in the city administration of health care, the developing of outpatient technologies, the effective use of the expensive equipment. According to this the efforts of the Comittee of Health Care should be directed to:

The finance of the health care system today is characterized by 2 tends: insufficient finance and ineffective using of funds. The debts of treatment and prophilactical organization to city monopolists such as Lenenergo, Lentech, Vodocanal, PTC, etc. is rising. There no effective economical ways for intensification of treat process in the city administration of health care, the developing of ambulatory technologies, the effective using of the expensive equipment is not enough. According to this the efforts of the Comittee of Health Care should be directed to:
- the developing of the system of perspective and present planning of developing the health care system;
- the rationalization of using the health care funds considering the limited finance;
- the rising of the control of the rational and purpose using the funds of health care;
- the providing stable incomes of budget funds and rising the volume of means outside of budget finance.
For optimization of using the finance resources of health care should be made the followings:
- transition to the system of complex regional planning of health care;
- the developing of mechanism of panning the medical care on the base of the city program united all kinds of medical care with dividing the financial sources: budget, insurance, and etc., according to the Russian legislation;
- the wide using of different finance mechanism for the providing of stable activity of medical organizations;
- the calculation of the costs of regional programs of medical care to minimize the part of the outcomes for the health care in 1998 budget to acceptable level;
- the effective using of federal funds and territorial funds OMI;
- the developing of international system of purpose projects and investing the funds of foreign investors;
- the widening of spectrum of paid-services in medical organizations, according to the legislation;
- the complex inventarisation and economic analysis for the purpose of indication the spheres of non rational distribution and using the resources;
- the transition to the divided cost calculation of different kinds of medical care and planning directed to the rational using of the sources.

The reform of pay system of medical care in organizations, which are financed by the Committee of Health Care supposes the followings:
- the transition to the paid treatment of the patients;
- the payment division of the stationary treatment according to the intensity and level of difficulty of treatment;
- the creation of effective economical stimulus of the development ambulatory technologies;
- the rising of control of Health Care Committee over the forming and expenses the salary funds of the organizations;
- the developing and using methods of medical-social and economic improvement the necessity of budget funds, prognoses of the effectiveness of using budget
funds in construction and repairing the main founds, buying of equipment, creating different centers and realization of programs;
- the realization of complex program of economy the resources;
- the creating of system of centralized distribution and service for medical
organizations of the city based on competition;
- the creating of working system of financial control with using specialists
from State Administration of Health Care;
- the further developing of control services over the activity of private
medical organization.

6. The structure and organization of medical care.

Today the structure of health care - outpatient, stationary, emergency- is expensive and ineffective. It�s necessary to change the structure according to the needs of population for medical help, possibilities of buildings and equipment, and to the dividing of the city to medical constituencies.

For this purpose it�s necessary to prepare a general plan of the developing of
the system of health care organizations, taking into consideration the activity of private and state organizations. This general plan will be the base for providing changes in the structure and location health care organizations in St.Petersburg.

The unified standards of volumes of medical help should be inculcate.

One of the main direction in organization of the medical care to the population is the transition from the expensive inpatient to the outpatient care.

Outpatient-polyclinic help.

The development of institute of family medicine takes considerable position in the reforming of outpatient care

In the same time it is necessary to point out that most important part of the primary health care in the years to come will be played by children and adult polyclinics with staged transition to the general practice (family medicine). It is necessary to prepare legislative base and increase responsibilities of district physicians (both adult and children) with changing accent to the consultancy work.

The main direction of the reform of primary care is connected with the followings:
- the developing of new polyclinic model oriented to the certain patient, and ideology of family medicine;
- the introduction of gradual payment system;
- the development of the centers of outpatient treatment, the schools of self-control for diabetic patients, the centers of medical help for people, the cabinets of medical prevention.

Also, it�s necessary to create the cabinets of general practice, to decide a question about competition among the physitians in the situation of applying for a job, to create a special organization for studying the opinions of citizens.

Moreover, in outpatient care geriatric services should be developed, programs of prevention of cardiovascular diseases and rehabilitation after them, early cancer detection, improvement of dental care to population of St.Petersburg, including privileged categories, etc.

Dental care

Very high rate of dental cavity disorders which show no tendency to decrease place a high demand on dental care system. In the same time due to peculiarities of the organization of this service and its resources necessary dental care available to only 1/3 of all demanding it. Possibility to have tooth prosthesis for free have only one-tenth of all have right for it (privileged categories of people).

Development of dental care for citizens of St.Petersburg should go along the following lines:

reorganization of the system of dental care administration taking into account new situation
determination of the guaranteed volume of dental care basing on real demand including privileged citizens
combining possibilities of state-owned, municipal and private systems to overcome deficiencies of dental care service and increasing availability of dental care
development and implementation of modern technologies in dental care, methods of planning, monitoring and evaluation of regional programs of dental care
complex decision of the problems of resources allocation for dental care including questions of staffing, equipment, financial-economic and informational problems

Inpatient care

The development of the hospitals will be directed on the rising of medical quality by more effective use of beds fond, the reduction of unproductive outcomes, the rationalization of outcomes for purchase of drugs, medical equipment, and introduction of new technologies.

For these purposes the beds fond will be divided into the followings:

- the hospitals of the intensive treatment;

- the hospitals of health recover (rehabilitation);

- the hospitals for long treatment of the chronicaly ill;

- the hospitals for medical and social help.

Division of the patient flow will help to use expensive equipment and other material goods more rationally, decrease length of stay in intensive care hospitals, decrease number of beds and obtain economical effect.

The work on increased effectiveness of the use of hospital beds, decrease in its number and closing of hospitals with unsatisfactory material basis, which prevents those hospitals from providing contemporary medical care.

Further development will undergo city specialized medical centers which are concentrating expensive equipment, highly professional staff, having high-end medical technologies

To ensure continuity of care on all stages of treatment it is panned to organize in all big hospitals of intensive care departments of emergency care. This will help decrease distance of ambulance car travel, time for starting qualified and specialized care which, in turn, will decrease mortality.

It is also panned to organize outpatient departments in such hospitals which will provide consultations to patients sent by GP. In cases of necessity patients will be selected for admission.

Further development will undergo hospitals and departments of nursing care, hospices with on-call teams for home visits.

To intensify usage of bed fond it is necessary:

develop and implement standards of medical care
implement into practical work modern medical technologies, purchase modern equipment which could really increase quality of care and effectiveness of treatment process.
to prepare and start implementation of goal-directed city programs on equipping hospitals with modern equipment with priority of Russian producers, programs of development of new technologies of care and diagnostics (endovideosurgery, laser surgery, etc.)
improve provision with drugs, introduce drug formularies for ordering drug utilization and prescription
revise staff structure of some intensive care hospitals with increase medical staff/ patient ratio
to develop different tariffs depending on intensity of work in institutes

It is necessary to integrate bed belonging to Research Institutes and Universities of Federal responsibility, other federal and ministerial level health care institutes into the system of inpatient care for citizens of St.Petersburg, including their integration into the system of compulsory medical insurance.

Sanatorium care

Sanatorium care in the contemporary economical condition should be provided in the framework of health care system to the patients (children and adults) with social important diseases, such as tuberculosis and cardiovascular diseases. For the more wide list of disorders (neurological, diseases of the digestive tract, hematology, etc.) it is necessary to have clinical basis for care for people from risk groups (Chernobyl accident and other).

Ambulance and emergency care

Changes in the morbidity structure with increase proportion of trauma, accidents and chronic illness complications demand strengthening of the ambulance services

Department of emergency care should be reorganized according to the reform of outpatient care.

City ambulance station will provide emergency medical care to the people of St.Petersburg and is basic structure of disaster medicine.

The future development of the city ambulance station takes place together with the reorganization of the emergency services departments of hospitals. There are plans for the transfer of some emergence service stations to the territory of the hospitals.

The ambulance and emergency service should receive new cars, equipment, connectivity and uniform. Unified standards of care should be developed and training will be standardized.

Care for mothers and children

The most important tasks in this field would be decrease prenatal and natal mortality, realization of the programs of improving children�s health, early diagnostics and rehabilitation.

It s necessary to improve technologies of care for pre-term babies. Further development is needed for the programs "Family planning", "Safe motherhood", "Orphans", "Handicapped children"

It is necessary to increase effectiveness of outpatient care, improve interaction with specialized services and outpatient departments of big hospitals, develop network of home hospitals, diagnostic centers, rehabilitation centers and sanatoriums

It is planned to activate the preventive work through complex of "early intervention": early diagnostic and correction of delays in motor and psychic development, disorders of eye and ear, improving diagnostics during pregnancy, diagnostic and correction of orthopedic problems. In the practical work of all obstetrical department WHO program "Hospital smiles to child" should be implemented: individual labor wards, close relatives present during labor, mother and baby in one room, free visits of relatives to the woman after birth, breast feeding. It is necessary to ensure interaction of woman consultations and obstetrical departments, creation of outpatient departments in obstetrical hospitals.

Further development is necessary for the centers with specialized care for expensive care and creation on their base outpatient-diagnostic departments.

To ensure availability of baby food for children under 2 years of age it is necessary to increase number of distribution points, increase number and quality of food. Accent should be given to stimulation of breast feeding.

7. Medical care in socially important disorders and medical-social services

Difficult economical conditions in the last ten years resulted in increase in rate and severity of socially important disorders: tuberculoses, alcohol and drug addiction, STD. Due to economical reasons in a very unfavorable condition now are psychiatric and oncological services, there are also many problems in providing infectious diseases care.

Interadministrative goal-directed programs

Resolution of some difficult social-medical programs of St.Petersburg possible only in case of interaction of different city services. The very important is participation of the Committee of health care in several complex programs "Vaccination", city program "Diabetes", city program on prevention of HIV infection spread, city program "Tuberculosis", interadministrative program "Reorganization of psychiatric care in St.Petersburg and development its material foundation", city program "Complex means on prevention and treatment of alcohol and drug abuse", city programs on prevention of cardiovascular diseases, prevention and early cancer detection, prevention and treatment of influenza.

It is necessary to develop and implement together with city Administration of interior, sanitation control and Immigration Department the program of screening and medical care for immigrants from medically unprosperious countries.

Continuing development of medical care is supposed to occur due to strengthening of the organizational structure of specialized medical institutes and their material basis, as well as implementation of more economically sound technologies of treatment and rehabilitation (day hospitals, rehabilitation departments).

Particular attention will be paid to the organization in health care institutes medical-social services.

Till present time there is no system of medical social service part of its functions are taken by several administrations and public organizations. In hospitals and other institutes due to low salary and shortage of junior nurses no attention is paid to those problems. In the same time due to social problems more and more expensive beds are occupied which demands organization of medical social service. This will help to decrease mortality, widen outpatient care and day care hospitals. Differentiated discharge with social problems taken into account will allow to decrease length of stay and obtain large economical effect.

Organization of full-scale social medical care will demand additional financial investments. It is envisioned to stage this process on first stags without additional money flow, due to decrease in amount of expensive hospital services

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support of existing material founds in working condition, reconstruction in time
usage of modern materials and technologies during reconstruction work
paying debts for reconstruction done and exploitation of new equipment
purchasing reserve generators for hospitals
implementation of energy-saving technologies and installation of energy-counting devices
installation of fire-control devices and signalization
in-time start of exploitation of new health care institutes
renewing equipment and its prompt repair
renewing cars for ambulance and emergency care
optimization of the number of cars belonging to the Health Administration responsible to Committee
support of Russian industry during production and introduction of a new technologies in health care

It is necessary to agree programs of construction and plan for reconstruction of health care objects with general plans of reforming municipal health care, scientifically sound demands of population in different kinds of health care.

Inventarization of material basis of health care objects which helps to create address program of their renovation, determine main stages and supply of different organizations with equipment, cars etc.

It is advisable t create system of operational control of use of material founds, introduction of energy-saving technologies.

According to the developed technical and economical plan to speed up informational support of health care administration and creation of informational network of city with satisfaction of needs in computer techniques.

10. Obligatory medial insurance

Constant delays in reimbursing health care costs, absence of the clear-cut criteria of quality of medical care, decrease in control over the activity of insurance medical companies in the system of OMI, unsatisfactory knowledge of the specific of work under insurance system by medical staff, conflicts between existing territorial legislation and law of the Russian Federation "On the medical insurance of the citizens of RF" calls for adopting complex of means legislative, organizational and economical nature. It is necessary to employ state regulation of the system of obligatory medical insurance.

Major tasks:

correct legislative basis of St.Petersburg according to the laws of Russian Federation taking into account existing practical experience of realization of obligatory medical insurance paying more attention to the principle of total coverage
revise and implement territorial program of obligatory medical insurance in St.Petersburg, develop and implement methods of economical explanation of the program and its use for the planning and regulation of the volume of medical care and needs in financial resources
develop unified approach to the quality assessment in the OMI system
develop recommendation on the tarification of all types of medical care in the OMI system taking into consideration place of serving and obligatory scheme of exchanges between administration on Health Care and insurance companies
create mechanism of transition to the annual cycle of tarification of medical care basing on the year tariff, to describe sequence of preparation, signing and correction of the tariff agreement, bind it to the inflation level
create city data base of insured with possibility to access to this data base for every interested site (in border of their competence)
create system of operative and calendar control over cash flow in all structures working in OMI system
create unified system of realization of rights of insured: on the guarantied health care, choice of medical institute and physician, choice of insurance medical organization
create list of the types of medical care that are subjected to tarification and covered by OMI
create mechanisms of economical interests in effective work of departments and physicians
elaborate ways of financing preventive measures
develop recommendations on the provision of medial care and fee for services given to the people not included into territorial OMI system (staff of police, army, etc.)
provide constant interaction between Committee on Health care and Territorial Found OMI by creating working group on coordination of activity and remove of functional overlap
create mechanisms of operative control with the aim of punishing insurance companies for not covering medical services and insurers for not providing means to the found

11. Drug provision

Final revision should undergo the Concept of drug provision for the people of St.Petersburg and Concept of the organization of drug provision for privileged categories of people of St.Petersburg.

Further development of pharmaceutical industry is basing on complex of actions divided into four groups: retail, distribution, production and creation of administrative system

The plan of development of pharmacies network suppose: formation of state pharmaceutical sector, preparation and selection of the objects of state property, state regulation of pharmaceutical activity, opening of pharmaceutical markets and new pharmacies, development of social programs of drug provision for the poor.

Development of the state regulation of the distribution system is planned to be based on: transition to the optimal licensing and accreditation system, creation of the united informational pharmaceutical system which will provide information on companies, results of quality control of the drugs and prices.

To foster development of the Russian medical and pharmaceutical industry it is planned to help to produce drugs by placing city order on the biggest factories in St.Petersburg and by supporting packaging and blistering on basis of several pharmaceutical factories in St.Petersburg

Drug provision for privileged citizens and management system: system of drug provision for privileged should be strictly centralized with state system of purchase planning, distribution to districts and guarantied provision of drugs. For this it is necessary: financing of drug provision through protected line in city budget, purchasing drugs centrally on competition basis through expert committee, creation of state system of planning purchasing, distribution through districts and guarantied provision, creation of plans for monthly and quartile purchasing of drugs taking into consideration existing regulations and volume of budgeting, creation and implementation of informational system of existence and movement of pharmaceutical means, creation of data basis on patients with privileges, creation of city and district commissions on drug provision for privileged categories, and controlling receipt writings.

12. Human resources and education

Unsatisfactory effectiveness of the reforms of city health care partially resulted from the absence of scientifically based and socially oriented staff policy, development of which in the contemporary situation calls for:

scientifically based prognosis of the demand for the different categories of medical personnel taking into account changes in social-economic and demographic situation structure of morbidity and basing municipal order for preparation of physicians and nurses on these data
provision of physicians/nurses ratio corresponding to the major tasks of the health care reform, creation of the municipal training order for physicians and nurses
formation of the system of continues education for managerial level personnel, physicians and nurses, also working mechanisms of the control over adhering to the demanded period and quality of postgraduate training
creation of the system of quality control for physicians and nurses
creation of the conditions that would promote implementation of the standards of professional medical education and control over their implementation
help in the carrying out research work in the medical schools and research institutes and implementation of the results in the practical work as well as in the education
organization of the center for postgraduate education of medical ad pharmaceutical personnel on the basis of MAPS ad SPb Chemical-Pharmaceutical Academy with participation of the medical schools, research institutes and medical institutes of the city

13. Social protection of the health care personnel

In the situation of economical crisis which goes through all spheres of society the most important problem became social protection and social guaranties of health care personnel. In this respect it is necessary t support initiative of the Ministry of Health of RF o revision of the system of payment to health care personnel.

It is necessary to return to the system of placing orders by Health administrations on the undergraduate and postgraduate education and training of specialists in the health care institutes and medical schools.

It is necessary to create and maintain data bases about vacancies for physicians and nurses in the medical institutes all over the St.Petersburg for more rational use of the existing human resources.

Present an initiative on attraction of additional budget and non-budget means for the solving questions of social protection and social guaranties to the health care personnel:

before new system of the salary will be put into action discuss the question on extra payment to the lowest categories of the health care personnel to rise their salary up to the level of poverty line
before new vacation law will be passed create in the budget of St.Petersburg a line for financing additional vacation time for health care personnel
create program of the reconstruction of medical institutes according to the demands of "safety and hazards on workplace" law
provide every year free-of-charge screening and fluorography of health care personnel working with hazardous materials and industrial factors (order of Ministry of Health N 90 from 14.03.96) and also oncogynecologists screening
create goal-directed program which will provide retraining of the personnel dismissed from Health Care System
decide the question on increasing health of children of health care personnel in the time of school vacation
decide the question on living conditions of health care personnel
provide free-of-charge sanatory cure and rehabilitation for health care personnel
activize activity of association of practical medicine to protect interests of health care personnel on the regional level
introduce risk insurance for health care personnel (malpractice claims insurance)

14. Development of medical science and medical technologies

Among major tasks for the science are: analysis and evaluation of the tendencies of changes in health of population, formation of the long-term strategy of health protection, prognosis of the morbidity level and development of scientifically sound basis of combating with most widely spread diseses, which making most damage to the health of society

Successful resolution of those tasks is possible only in case of significant increase in effectiveness of fundamental and applied medical research, speeding up introduction of scientific advances into practical health care.

For St.Petersburg most important principles of science development are:

strengthening of the preventive direction of scientific research. Development and implementation of scientifically proven means of creation healthy life style, environmental protection, further development of primary prevention of infectious and noninfectious diseases
study of the conditions of health preservation. Development and implementation of the scientifically proven methods of diagnostic and treatment of widely spread diseases, which will lead to the decrease in the mortality, morbidity, handicap rate and trauma rate.
development basing on special medical-biological, clinical and socio-hygienic research optimal norms for most complete satisfaction of demands of the population in different types of health care
participation in different organizational programs dedicated to the treatment and health preservation, as well as programs of the health care development

Priority problems of the medical science will be solved in the future ten years through state and industry programs of the scientific research. According to these programs the new and effective methods of diagnostic and prevention will be developed for the cardiovascular diseases, malignant neoplasia, major diseases of motherhood and childhood, alcohol abuse and mental disorders, disorders of pulmonary tract. New methods of correction of homeostasis will be developed and implemented, methods of reconstructive and restorative surgery, transplantation and apparatuses for organ ttransplant.

Development and implementation of the new forms and methods of the prevention, diagnostics and treatment will be dedicated to the decrease of morbidity, handicap rate and mortality rate, which in turn will influence life expectancy and active period of life and so will increase its industrial potential and so will influence tempo of scientific and social progress.

15. Legislative foundation of health care

In the last few years in the legislative system a new situation has appeared which stems from the following:

in 1992-1997 during changes in al laws of RF the deficit of new legislative documents has appeared
former system of regulation of health care questions with help of centrally issued normative documents was changed to the principle of their concomitant adoption by federal government and territorial governments. In this situation number of federal regulation significantly decreased
a new tendency has formed in which mot aspects of the situation is regulated by laws, though before most aspects were regulated by normative acts and orders of administrations

Changes in the situation in legislative basis calls for changes i the legislative base of St.Petersburg and its agreement with acting laws of Russian Federation taking into account real social and economic situation

Major direction in development of legislative base should be activation of preparation and adoption of regional laws and other normative documents which should solve the following problems:

compensate deficiency of federal normative acts on legislative regulation of health care
create optimal conditions for operational solving the problems which are appearing during practical realization of reforms n health care and medical insurance
create normative mechanisms which realize socially important regional programs in the health care

In the process of improvement of legislative base of health care in St.Petersburg it is necessary to create several packages of normative acts, including:

organization, planning and financing of health care
development of the OMI system
organization of drug provision and some types of heath care

It is necessary to create and submit to the Legislative Assembly of St.Petersburg several laws:

"On the basis of health care organization in St.Petersburg"

"On the drug provision for privileged categories of citizens in St.Petersburg" and other

Moreover, it is necessary to revise and upgrade existing normative acts of the Administration of St.Petersburg regarding health care, create and adopt new documents on different aspects of health protection. It is necessary to create and adopt new edition of the program and rues of the obligatory medical insurance in St.Petersburg, to prepare normative acts, which will regulate organization of care in socially important disorders, geriatric services, dental care, ambulance services, as well as documents regulating planning and adoption of the preventive programs.

16. Informatization of health care

The reforms are impossible without development and implementation of the unified policy regarding informatization of health care and every medical institute.

It is planned to create Coordination Council on information technologies under Committee of health care, the major task for which would be realization of state policy in the informatization of health care and creation of global informational space of St.Petersburg

Realization of unified policy of informatization based on resolution of the following tasks:

implementation of the informational systems and technologies in the activity of the administrations of health care in St.Petersburg, which will include Committee of Health Care, Territorial Fond of the OMI, district administrations of health care, organizational-methodic offices basing on the unification of data bases, software and telecommunicational technologies, including Internet-technologies.
informatization of the medical institutes by implementation of typical computer systems, standardization of the date formats, user interface, compatibility of thee systems and support and development of such systems
creation and development of the city medical informational systems for the ONI (united insured data base), for the flow of privileged drugs, medical statistics, medical personnel, rate of infectious diseases.
creation of the personal registers, including data bases of insured in the OMI system, those having privileges on drugs

17. Registration and reporting in health care

Timely and reliable information is one of the major factors in effective management.

It is necessary to improve existing systems of registration and reporting with the following major requirements:

provision of operativity and reliability of information;
selection of those indicators and regimes of reporting which would ad maximum satisfy needs and goals of management, create possibilities for objective control and timely decision making
unification of methods of information selection and processing, provision of comparability of data between different institutes
staged approach to the registration, reporting and information selection

It is necessary to create differentiated systems of indicators and reporting forms, specially dedicated for different levels of administration.

It is necessary on the unified methodological basis provide agreement between different reporting and registration systems: medical documentation connected with patient service, with diagnostic and treatment process; forms of medico-sanitation statistics; state reporting forms; accounting, including operative information according to the selected services and types of expenditures; other forms of registration and reporting used in medical organizations

18. International collaboration

In the previous years in St.Petersburg international collaboration is actively developing. Today in the city several programs and projects dedicated to the different aspects of the health care reformation are operating. Such collaboration is very important as help to realize significant scientific and practical potential of city health care and is a significant source of additional financial means, which are very important in present socio-economical situation.

Widening of the zones of common interests, increase in the number of international projects is helping to implement new technologies and new financial mechanisms increase in quality of medical care, decrease costs in health care in general. Very important question in this respect is financial support from the side of foreign partners.

City needed to develop international contacts on the questions of health care reform, leading medical technologies, training of personnel, prevention and treatment of socially important diseases, following the international treaties regulating civil rights in the field of health protection.

19. Sanitation control

Sanitary-epidemiological well-being of the population is secured by complex of organizational, technical, medical and other means, dedicated to the decrease of hazardous influences from the environmental factors, places of living and recreation. The most important activities in this direction are:

provision of the population with good quality drinking water in sufficient amount
creation of the non-hazardous living conditions
provision of the adherence to the hygienic standards
introduction into the practice of city administration system of population risk estimation
provision of socio-hygienic monitoring
creation and financial support of goal-directed programs of the prevention of infectious and non-infectious diseases
constant information flow to the population on the environmental conditions, hygienic demands and means for health improvement
creation of the system of regional hygienic standardization
introduction of the economical mechanisms of the health care management (disincentives, ecological insurance)

20. Priority settings. Major stages and time-table of the concept realization

Presented concept describing principles and directions of the health care development of St.Petersburg until 2003. In every part of it several means of stabilization and increase in effectiveness of health care are proposed. In the same time in the situation of the finical means shortage it is necessary to select priorities from the lists outlined above and form stages in its realization.

The main directions are:

- emergency help;
- treat and preventive help to mothers and children;
- geriartrical service;
- social-important medical services (tuberculosis, drug addict, AIDS,
oncology, STD, blood transfusion service);
- reorganization of the administration and the structure of health care in
St.-Petersburg.

Selection of the aforementioned directions based in first place on the demographical situation in St.Petersburg. Decrease in birth rate, decrease in potential for regeneration are calling for redistribution of means for motherhood and childhood protection.

In the same time increase in the number of elderly people both in the population structure and in the structure of hospitalization calls for development of geriatric services.

Changes in the morbidity structure, increased (due to increased trauma and accidents) mortality among working age population lead to the increased demands for the emergency service. It is explaining why emergency medicine is selected as priority.

Realization of the aforementioned directions demands adequate financing. In the same time in the system of the health care there are still internal reserves which can be put into action after reorganization of the structure and management in health care.

Realization of the Concept will proceed through three stages during 1997-2003. It is oblige that on every stage clearly seen by people of St.Petersburg results are obtained. Financing of the projects on the first stage will be done in the limits of the health care budget 1997, planning amounts for 1998 and means of OMI as well as from foreign sources and other means. Major effect should be achieved from the usage of the internal reserves of heath care and changes in administrative and legislative decisions in the limits of existing budget. Second and third stages are based on investments. It is supposed that competition will be organized and selected project will be agreed upon.

On the first stage (1997-1998) the main tasks will be the followings:
- the development and approve of the legislative acts in sphere of health care and medical insurance;
- the providing of financial stability of health care system by the way of reduction of the debts;
- the introduction of regional guarantee service of medical help quality;
- the improvement of drugs providing for people with the special social guarantees;
- the improvement of the system of health care administration, medicine of catastrophes, creating the emergency departments in the hospital;
- the improvement of the payment forms and organization of ambulatory-polyclinic help for gradual transition to general practice;
- the realization of the goal-directed for diabetics;
- the realization of measures connected with the such programs as "Tuberculosis," "Geriartrical service," "Vaccine prophilaxis," "AIDS and virus hepatitus B and C," the preparation and the approvement of the projects of realization of the second stage of the conception.

The tasks of second stage (1999) are:
- the structure reconstruction of stationary medicine help and reorganization of beds fond;
- the further development of alternative forms of treatment;
- the further development of family medicine program and the creating new cabinets of general practiians;
- the improvement of stuff policy, which include the creating of aftergraduate centers, the forming of informational system "Medical personnell" medical stocks, medical re-training of the personnell;
- realization of projects such as "Safe motherhood," "Family planning," "The prophilactic of sexual illnesses," "Psychiatric service";
- making the researches in sphere of economics, and administration of Health Care, directed on the realization of third stage.

The tasks of the third stage (2000-2003)are:
- the conduction of structure changes of ambulatory-polyclinical help, and the reform of stationary medical help;
- the preparation and realization of the program of wide using modern medical technologies in St.-Petersburg, and creation the regional centers;
- the creation and development of infrastructure of modern producing of medical technics, materials, drugs;
- the further realization of the conceptions projects.

The solving of these tasks provides considerable rising of the effectiveness of city system of health care.

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