In today's society, the rights of the individual and the rights of the patient play an increasingly important role in health care planning. At the same time, the responsibility of the state for protecting the health of the entire population implies the obligation to take measures aimed at ensuring a safe and healthy natural and social environment.
The most difficult questions are: What is medicine - art or science? Are the concepts of "medicine" and "health care" the same? And what is medicine: general pathology, general therapy, general therapy or general prevention?
Modern English scientists consider public medicine as a part of medicine responsible for protecting and improving the health of the human population as a whole, and not just for treating an individual in a clinic - it exercises control over health care at the national, regional, district and local levels.
The ethical requirements for public health policy are based on the basic concepts and moral values accepted in society. If saving human life occupies the highest place in the scale of values, then all possible measures necessary for this purpose must be taken, regardless of conditions and costs.
At the social level, medical ethics concerns the distribution of medical resources, their availability and social justice.
Availability of medicine- this is the right of every patient to receive medical care, the ability to pay for medical services. It is assumed that this responsibility should be assumed by society.
Justice is the right of the patient to receive medical care free from prejudice and favoritism.
Sickness and death can be seen as events predetermined from above, perhaps as a punishment for sins, an ethical imperative meant only to alleviate suffering, and preventive measures will be seen as an intervention opposed to divine will.
The implementation of health-approved measures aimed at the health of certain segments of the population may require the participation of society.
The tension between the rights of the individual and the needs of society is a constant public health problem.
There is a possibility that society will be forced to limit private rights in order to reduce morbidity and mortality, for example, from injuries among the population without specifying whose specific life will be saved.
For example, speed limits, enforcement of traffic rules, mandatory seat belt use, alcohol and anti-nicotine laws restrict individual rights while protecting individuals and society as a whole.
Also, some forms of mass use of chemicals are means of practical application of the principles of safety and protection of public health in general.
For example, water fluoridation, which aims to reduce the incidence of caries among children, means that the rest of the population is forced to drink fluoridated water, although this does not have any positive effect on their health.
The choice of ways to protect the health of the population has its supporters and opponents, for example, fortification of food products with vitamins and minerals, the method of using folic acid as the most effective means of preventing neural tube defects in newborns, etc.
In public health practice, methods that have been tested in the most developed countries ah, which have proven their effectiveness in prevention, and methods that are characterized by low cost.
Usage information systems in healthcare have ethical aspects, and first of all, in the matter of maintaining medical secrecy.
But the birth rate, mortality, incidence of infectious diseases, their mandatory registration and accounting, as well as hospitalization rates are a source of information for epidemiology and health care management.
The threat of the AIDS epidemic has provoked a public outcry in many countries, associated with the assumption of the possibility of infection as a result of accidental contact, which confirmed the need for greater public awareness.
The ethical side of the problem does not receive due attention in countries that spend more money on weapons than on health care. The health care share tends to be much higher in countries with liberal democracies.
The individual, like society as a whole, has certain rights and obligations in the field of health care. Responsibility for financing health care lies mainly with the state, however, there are a number of factors that determine the participation of the employee and the employer in paying for medical services, with an appropriate distribution of costs between them in this area.
Government agencies have overall responsibility for health care and the determination of the main policy in this area, the allocation of resources and the development of standards.
The ethical side of the problem of distribution of resources between primary health care services at the local level and inpatient medical institutions is very complex.
Ethics is not an abstraction.
The resources of health systems are not sufficient for all those in need of health care, which is where the most difficult problems of resource allocation originate. These problems become most acute in relation to especially scarce medical resources (drugs, types of assistance) that have vital importance for the patient, for whom the need far exceeds their number.
As a result, a contradiction arises between the ethical principle "life as a value" (according to which the doctor should strive to do the maximum possible for the benefit of his patient) and the need to choose who will receive medical care (and how much), and who will be left deprived. But why can't health care provide all those in need with the necessary types of medical care (even in the most developed countries), and why is there a sharp discrepancy between resources and needs?
Among the main (and in many ways interrelated) reasons for the existence of a shortage of medical resources, the following should be mentioned.
1. The very progress of medical science and practice. The progress of medicine leads to the emergence of more and more complex and high-tech medical methods. As a rule, more advanced and sophisticated methods are more expensive. The limited technical and economic capacity of health systems and services cannot provide all those in need with the most advanced and high-tech types of medical care.
In this regard, it is worth remembering that historically the problem of the distribution of scarce medical benefits was one of the first sources of the formation of modern bioethics as such. So, in the 60s. 20th century in Seattle (USA), the first (and only in those conditions) dialysis machine (artificial kidney) appeared. To solve the most acute moral problem of choosing which of the needy will be assigned life-saving dialysis, a special commission was created, which began to be called the "divine committee". Her work was one of the first examples public comment ethical issues in medicine.
The problem of fair distribution is also aggravated due to the general democratic development of society - people in developed democracies want to participate in decision-making, defend their rights and interests. In particular, various special groups (patients, their relatives, persons with disabilities, etc.) are active here, insisting on a more equitable distribution of medical benefits. Requirements for equal access to medical care, non-discrimination, fair treatment of patients, transparency in the distribution of resources, etc. increasingly politicized.
This is a natural process of expanding and deepening democracy, including in the field of health care, one of the most important for the life of society.
It should also be noted that the fundamental problem is not only to distribute medical resources fairly (and not only to have enough of them), but also to ensure that the distribution and use of resources occur to the maximum effectively. Medical care systems everywhere suffer from unproductive costs associated with unreasonable medical prescriptions, medical errors, increased expenses for the maintenance of administrative personnel, etc. With inefficient use of resources, the needs of the population are not satisfied, the necessary goals are not achieved (even with objective opportunities to achieve them ), but the severity of moral problems remains.
There are micro-, meso- and macro-levels of distribution of medical resources.
microdistribution refers to the individual activities of physicians who are forced to make resource allocation decisions in their daily practice. Average level(mesolevel) covers health care facilities as a whole as independent health care systems, as well as local health authorities. Macro level - these are decisions on the distribution of resources at the level of regional and government agencies healthcare management.
Distribution of health services
Society has two main questions to decide: how much of our scarce resources will we give to healthcare, and what type of treatment will we choose? To answer these questions, we need a distribution (or decision) system. There are three possibilities: the free market, command system, mixed economy.
In conditions market economy a decision is made on the allocation of health care resources in accordance with the change in the purchasing power of consumers. The command model will be based on the principle of planning the allocation of health resources in accordance with some predetermined need. mixed system combines elements of the free market with elements of the command model. In order to determine which of these systems is the most appropriate in any given case, we need to evaluate the performance of the distribution system.
Economists use two main criteria. The first is efficiency. Does the system create an efficient placement (one that is located on the GPV line)? If allocation is efficient, this means that the economy produces exactly the quantity and type of health services that society needs (in this case, distributional efficiency, or Pareto efficiency), although a certain point on the GPV line reflects to some extent society's preferences. . For example, if society were to choose hip transplants over other surgeries, then the economy would reach (efficient) point C rather than (efficient) point B in Figure 2.2. Also, if the economy operates on the GPV line, then it produces medical services at the lowest possible cost (production efficiency takes place). distributive and productive efficiency of markets (Chapters 7, 8 and 9).
The second criterion used by economists is fairness. In this case, we are interested in whether the distribution system is fair. This is, of course, a normative question, since the decision depends on a value judgment. Meanwhile, this problem is very important for the governments of many countries when they consider the distribution of medical services. For example, it has often been argued that the idea of social justice was central to the Labor government when it created national system health care in Great Britain in 1948. The concept of equity is difficult to analyze, but for the sake of simplicity we will make a distinction between horizontal and vertical equity.
Horizontal justice is associated with the equal satisfaction of an equivalent need. This means that, if the system of distribution of medical services is fair, it should treat people with equal ailments in the same way. Vertical justice, on the other hand, shows that we should treat different individuals differently. In the healthcare system, we can see this in the challenge of treating different diseases differently: those who have serious diseases (heart disease) receive more care than those who have relatively minor complaints (fungal diseases on the toes).
What does this analysis provide for a better understanding of health problems? Consider the following report from The Guardian, January 11, 1997:
“The government acknowledged today that there are an unprecedented number of critically ill patients in hospitals during the winter as doctors have warned that the National Health Service is going through its worst financial crisis in a decade. The British Medical Association (BMA) yesterday released a new list of areas of concern across the country where bed shortages and Money led to the postponement or cancellation of operations, the placement of patients in the corridors. Most hospitals have stopped performing all routine surgeries such as hip reduction to make room for the critically ill, and many health authorities and trusts are facing millions of pounds overspending... The National Association of Health Authorities and Trusts said the National the health service needs cash assistance in the amount of 150 to 200 million pounds. Art. to support hospitals during the winter. The BIA said that ... the need for hospitals to make 3% savings means that many services will be cut.”
The issues raised in the communication are obviously related to the growing demand for medical services, especially during the winter months. An analysis of the GPV makes it clear that this situation reflects one of two possibilities. Either hospitals will operate on the GPV, or within it (for example, point G in Figure 2.2). If they work on its frontier, they must choose between two or more ways to efficiently allocate resources (in this case, routine surgery, hip replacement, or critically ill surgeries), or they need to allocate more funds for medical care (shift GPV outward). If they are within their GPV, then there is no need to choose between two efficient options, since the initial placement is inefficient. All we need is to move the ineffective opportunities in such a way that we get more both routine surgery (hip replacement) and operations for the seriously ill.
Although this analysis is simplistic, it refers to the ongoing debate about changes in the way the NHS operates. Conservative governments headed by M. Thatcher and J. Major stated that the distribution of funds was inefficient (see point G in Figure 2.2), that is, we could get more from the resources at our disposal. The current Labor government, while in opposition, has said that the problem was (and is) a lack of resources; in other words, since hospitals are still operating on their GPV (they are efficient), they need more resources to shift the GPV line outward.
1. Rarity is fundamental economic problem, which arises due to the fact that unlimited needs must be satisfied through limited resources.
2. The ever-increasing number of the elderly population, growth real income, as well as improvements in medical technology - all this has led to an increase in the demand for health services.
3. Limited resources or factors of production are land, labor, capital and enterprise.
4. Rarity means having to make a choice, every choice has an opportunity cost.
5. The Production Possibility Frontier (PPF) is a useful tool economic analysis, which shows all possible combinations of the maximum production of two goods, when all available resources and the best technology are used to the fullest. G 'PV reflects the economic concepts of choice, opportunity costs, efficiency, the law of increasing costs.
6. Resource allocation systems are evaluated in accordance with the criteria of efficiency (distributive and production) and fairness (horizontal and vertical).
7. A distribution system is Pareto efficient if it is not possible to reallocate resources in such a way that the situation of some would improve at the expense of the situation of others.
Geopolitical prospects for the development of the country, issues of providing national security, economic growth and the improvement of the well-being of Russians directly depend on the level of physical and spiritual development of people, their professional activity, and longevity. The priorities of the state social policy should be to preserve the intellectual and labor potential of the nation, improve the psychophysical health of people, their quality of life.
Currently, the state of health of the population causes reasonable concern. Analysis of statistical data indicates a deterioration demographic situation in the country, an increase in morbidity, a sharp increase in premature mortality of the able-bodied population, an increase in the level of labor losses from diseases, injuries, disability, deterioration in the reproductive health of the population. The death rate exceeds the birth rate by almost two times, which leads to a natural decline in the population approaching 1 million people a year. The mortality rate of the able-bodied population in Russia exceeds that in the European Union by 2.5 times. According to the World Health Organization, in terms of life expectancy, Russia ranks 134th among men and 100th among women in the world.
As noted in the next message of the President of the President of Russia V.V. Putin to the Federal Assembly of the Russian Federation, the mortality rate increased by 10% over three years, the average life expectancy decreased from 67 years in 1999 to 64 years in 2002.
The socio-economic crisis has expanded the range of negative factors affecting the health of the population, and has strengthened the negative trends that had developed before it. In the structure of morbidity, along with cardiological and oncological diseases, various kinds of sociopathies come to the fore: tuberculosis, venereal diseases, mental disorders, alcoholism, drug addiction.
The burden is steadily growing economic costs society for compensation payments related to the deterioration of the health of workers. Annual insurance payments on compulsory social insurance against industrial accidents and occupational diseases exceed 25 billion rubles, for payment of temporary disability of workers - about 47 billion rubles.
Formation financial resources health system occurs in the process of production and distribution of gross domestic product (GDP). The World Health Organization recommends spending at least 7% of GDP for these purposes. In most developed countries, health care costs account for 8-12% of the gross domestic product. Health spending in Russia from all sources, including federal budget, budgets of subjects of the federation, municipal budgets, means of compulsory and voluntary health insurance in last years do not exceed 2-4% of GDP.
Russia today needs to build an effective financial and organizational model for the development of healthcare, taking into account its own experience state regulation this area and the best experience in the development of market relations in the health care of foreign countries.
The limited health resources make it necessary to develop some principles for the allocation of these resources.
There are various levels and types of resource allocation.
Geographically, there are:
distribution of resources between different territories of the country (subjects Russian Federation);
distribution of resources within territories.
From the point of view of medical technologies, there are:
distribution of resources between types of medical care (inpatient, outpatient);
allocation of resources between intensive care and aftercare;
distribution of resources among various medical specialties within species;
distribution of resources between different medical technologies within each specialty.
From the point of view of types of costs, we can distinguish:
distribution of resources for current medical care;
distribution of resources for capital investments (development).
From a social point of view, we can distinguish:
distribution of resources for the poor;
distribution of resources for the wealthy.
Decision-making on all types of distribution can be carried out in various health systems at various levels - from the government level to the level of the individual.
At the same time, it is important which principles society seeks to implement by choosing certain decisions.
The demand for fairness or the demand for efficiency can be put at the forefront. Most often, an attempt is made to take into account both requirements.
But the very concept of justice can have many interpretations. Let's consider only some of them.
Thus, with a purely market orientation, a society may consider it fair that each of its members receive medical care to the extent that he is able to buy it.
With a purely social orientation, all members of society, regardless of how much they invest in health care (through contributions, taxes), receive the same medical care under the same conditions under the same conditions.
It is clear that health care systems with both a purely market and a purely social orientation cannot exist in practice.
Purely social systems based on central planning and distribution of resources do not function either, since those in power always make exceptions, at least for themselves, having free access to medical care, which is several times higher than that available to others. Moreover, even in pure social society there are always people for whom their health (at least at the moment) is the highest value, and they are ready to pay and pay for medical services of the highest quality (though not always officially).
A compromise is the option of providing medical care, which society considers necessary to provide to each member, on the terms of social justice - the same care for the same conditions in the same conditions, regardless of income. This principle is implemented by social (mandatory) health insurance systems.
However, society takes into account the interests of its well-to-do members, allowing them to receive the best medical care in exchange for additional funds through voluntary medical insurance. best conditions.
In developed rich countries, as a rule, any medical technologies available to all are included in the social insurance system, but well-to-do citizens have a wider choice (for example, in Germany - the choice of a doctor in a hospital), unscheduled receipt of planned medical care, better service conditions.
Less wealthy countries do not include all types of medical care in the mandatory package of services (compulsory health insurance program).
Another concession to market justice is the exemption of wealthy members of society from mandatory health insurance premiums.
This, of course, is beneficial to wealthy citizens, since voluntary insurance on the basis of individual (rather than collective) risk costs them, on average, significantly less (high wealth, as a rule, allows you to maintain a decent state of health through a healthy diet, good conditions living and recreation, sports). Of course, there are exceptions, but on average, the rich have a lower risk of consuming health care than the poor.
Therefore, in order to expand the financial base of compulsory health insurance, it is made universal, allowing additional voluntary health insurance.
In order to take into account the requirements of market fairness, an upper income limit (threshold) may be established, from which contributions for compulsory health insurance are collected.
Health economics also considers more subtle definitions of equity:
the concept of equal access and equal use for the same needs - horizontal justice;
the concept of unequal baseline conditions and the justified degree of treatment inequality - vertical equity;
The notion of fairness as equality of health is unrealistic, since health depends on genetic factors, conditions and lifestyle, and so on.
Let's look at some options for ensuring geographic fairness.
In Russia and Great Britain, until recently, financial resources were distributed by regions to maintain the existing network of medical institutions, that is, the distribution was mainly supply-oriented.
To achieve the demand for fairness - equal access under equal conditions - in the UK Working group Allocation of Resources (RGRD) proposed a formula for the distribution of centralized health resources across regions. This formula attempts to allocate funds based on a measured need for health services.
The following diagram illustrates the concept of "need".
For example, in the case of a woman with breast cancer, the following scenarios are possible:
she has a desire to be treated, to demand treatment and to receive it, if the doctor agrees that the treatment is necessary - the desired demanded need;
she has a desire to be treated, but does not care about visiting her doctor - a desired unclaimed need;
she has no desire to be treated, not realizing the seriousness of the situation - not a desired unclaimed need
The GRRR formula makes an attempt at a rough estimate of the needs of the population of the regions in health care resources. It takes into account the following factors:
population;
age and sex composition of the population;
incidence rate;
mortality rate;
qualifications of doctors;
cross-flows of patients;
the economic status of the region (urban, countryside).
The need for various services varies by region. Therefore, all services are grouped into 7 categories:
inpatient services (excluding psychiatry);
general somatic outpatient services;
outpatient services for the mentally ill;
outpatient services for the disabled;
home services;
ambulance services;
family doctor services.
For each category, the relative requirement for each region is calculated, then the relative requirements for all categories are summed for each region to obtain a total requirement.
The introduction of this formula led to a political scandal, as resources were redistributed from the wealthy regions of the South East and London to other regions. However, the formula is gradually being implemented, which contributes to a more equitable distribution of health care resources. But equality of access has not been achieved - only equality of costs for the same needs.
In Russia, when compulsory health insurance was introduced, the “Procedure for determining the average per capita standards for financing a territorial program of compulsory medical insurance” was developed and approved. the formula is oriented both to the supply (the coefficient of previous costs reflects the cost of maintaining the existing network of medical institutions) and to the need, since it takes into account the age and sex structure of the population.
This formula is adequate for the current legislation on compulsory health insurance, according to which only current medical care is paid from the funds of compulsory health insurance, and the development budget remains at the disposal of the health authorities.
Consider the contradiction between fairness and efficiency in resource allocation.
Fulfilling the requirement of equal access with equal rights is practically unattainable, since for its implementation it would be necessary to have medical services of all kinds, even rarely used, in every locality. But this would require huge costs from society. Therefore, services that are statistically rarely used, services that require the use of expensive equipment and doctors of narrow qualifications, are concentrated in selected settlements, as a rule, in regional centers. This allows efficient use of resources, but violates the requirement of equal access - with equal rights to receive care, residents of remote settlements must spend their time, bear transport costs in order to exercise their right to receive specialized or expensive medical care.
However, in all countries, the requirement of efficiency is taken into account when allocating resources, and the requirement of equal access is implemented within the region (in Russia - a subject of the Federation), and not a locality.
Decisions about the structure of care in terms of medical technologies are guided by the concepts of efficiency in terms of both clinical outcome (clinical efficiency) and distribution efficiency financial resources and performance.
Thus, the same disease can often be treated on an outpatient and inpatient basis. Thus, there are two types of medical technologies. From the point of view of health care costs, outpatient treatment is much more effective, but from the point of view of society, this is not always the case - a person wastes time, bears transportation costs, is nervous in queues for doctors, his examination is delayed, and recovery is often delayed. Thus, from the point of view of the interests of society, outpatient treatment is not always the most effective.
In reality, the distribution of resources between inpatient and outpatient care is carried out when making a decision on the allocation of funds ( capital investments) for the construction or reconstruction of relevant medical institutions. These solutions are in different countries can be taken at the level of the government, region (in Russia - a subject of the Federation), municipality. These decisions are influenced by the existing need for this type of assistance, which is largely shaped by doctors under the influence of payment methods. Thus, the system of payment for medical services is one of the mechanisms for allocating resources between inpatient and outpatient care.
In resource-constrained settings, one has to decide whether to invest in a preventive program or in improving patient care. There are alternative medical technologies for the treatment of the same disease. For sound decision-making, it is necessary to conduct an economic assessment of the effectiveness of various targeted programs or medical technologies.
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Now we can return to the criteria success proposed in the Department of Health document "Health of the Nation: A Guide to Mental Illness" (Department of Health, 1993): adequacy, equity, accessibility, effectiveness, relevance (acceptability) and effectiveness. While we must again caution against the risk of bias in making comparisons between groups (because of the difficulty of matching like with like), the evidence presented in this article suggests that people in the short-term hospitalization group received less support in terms of these criteria. in the community than members of either of two groups of former long-term patients:
Indicators service utilization in the short-term hospitalization group were lower, with the exception of an increased level of hospital care utilization (more high percent usage and higher costs).
noted difference in settlement patterns: members of the short-term hospitalization group were less likely to live in specialized housing or receive appropriate informal support instead. Higher housing costs for long-term hospitalization groups opened up access to more resources for day-to-day support.
In a group short-term hospitalization overall costs were significantly lower.
On the non-compliance Equity measures indicate overall lower levels of service utilization, lower costs, less likelihood of living in specialized housing, and lower levels of informal support—despite on average identical or higher levels of need for members of the short-term hospitalization group compared to the other two groups.
Correlation analysis between the characteristics and needs of group members, on the one hand, and care costs, on the other hand, reveals the presence of fairly strong positive relationships for the two groups of former long-term patients and much weaker ones for the short-term hospitalization group.
Other equal conditions, within each of the two long-term hospitalization groups, the more favorable outcomes at the individual user level stemmed from more high level support (indicated by higher costs), but this did not seem to occur in the short-term hospitalization group (although we were not able to test the significance of these associations as rigorously).
The total weight of these comparable data, brought together in a way that can be seen as retrospective and compromise rather than purposeful and planned, should be the starting point for more detailed consideration targeting resources in community mental health care. In particular, are there lessons to be drawn from the experience of organizing, funding and directly providing community care to the two long-term hospitalization groups to guide them as they work to improve the quality of care for others and increase its responsiveness to client needs? In other words, can actions be taken based on the analysis that can help improve efficiency and equity in the mental health care system? Concluding this article, we make some suggestions regarding the resource environment for community care.
