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At the same time, any changes in the territorial organization made without taking into account the point of view of the population are considered unacceptable, even if they eliminate distortions in the reforms implementation and are aimed at restoring its ideology. Thus, in April 2008, the RF Constitutional Court issued a ruling on the issues concerning the introduction of changes in the territorial organization of local self government in Kalinigrad Oblast40. In 2007, the authorities of Kaliningrad Oblast had attempted to establish a two-tier structure of local selfgovernment instead of the artificially created city okrugs, as it had been envisaged by the concept of municipal reform. They were planning to create two new municipal formations in the territory of Baltiisk City Okrug, one of which the City of Baltiisk was to receive the status of a city okrug, while the second the Settlement of Primorsk - was to be accorded the status of an urban settlement and included in Zelenogradsk Municipal Raion. To a great extent, the planned transformations had been provoked by a conflict between the regional and municipal authorities. The RF Constitutional Court abolished the contested oblast law on the grounds that the populations opinion had not been taken into account when carrying out the transformations. At the same time, the Ruling of the Constitutional Court emphasizes that, in the event of the borders of territorial entities being changed in connection with the abolition of those municipal formations where local self-government is exercised and elected bodies are in operation, it is the instrument of referendum that represents the most adequate form of taking into account the populations opinion.

The apparent inadequacy of the territorial structure formed in the course of local self-government reform, as well as the failure of most of the initiatives put forth by regional authorities in order to transform it, increase the pressure for changing the corresponding provisions of federal legislation with the clearly visible expectations that the administrative factor will play a growing role this process. Thus, the new attempts at transforming Odintsovo Municipal Raion of Moscow Oblast into a city okrug, which were accompanied, in 2007, by acute conflicts and unprecedented administrative pressure41, were postponed on the initiative of the Raions head who had decided that, judging from his information, such a transformation could be carried Law of Tver Oblast, of 18 September 2007, No 97 ZO On Resolving, by Local Self Government Bodies of Tver Oblast, of Issues of Local Importance for the Settlements of Tver Oblast in the Year 2008..

Ruling, of 1 April 2008, No 194-O-P, with regard to the appeal filed by the administration of the municipal formation Baltiisk City Okrug of Kaliningrad Oblast and the Okrug Council of Deputies against the violation of constitutional rights and liberties by the Law of Kaliningrad Oblast On the Organization of Local Self Government in the Territory of Baltiisk City Okrug and by part 2 of article 27 of the Federal Constitutional Law On the Judicial System of the Russian Federation, and also with regard to the appeal filed by the citizens N.A. Gorshenina, N.I. Kabanova et al against the violation of their constitutional rights by the afore-said Law of Kaliningrad Oblast.

For more details, see Munitsipalnaia reforma v 2007 godu: osobennosti realizatsii [Municipal Reform in the Year 2007: The Peculiarities of Implementation]. Moscow: IEPP (IET), 2008, Section 3.5 (forthcoming).

out, in the nearest future, within the framework of other procedures42. However, no concrete projects of changing legislation in this sphere have been offered to the general public as yet. It is likely that the limiting factor here will be the provision of Article 131 of the RF Constitution, which envisages that the borders of territorial entities under local self-government should be changed only with the consent of their population.

Nevertheless, if the procedure of territorial transformations is considerably simplified, such transformations will involve not only the municipalities where there exist objectives preconditions for this initiative, but also those where the desire to change the territorial organization is caused by political reasons or economic interests totally unrelated to the efficiency of the institution of local self government.

An important innovation in the sphere of local self-government organization was the adoption, in the year 2008, of Edict of the President of the Russian Federation, of 28 April 2008, No 607, On Estimating the Effectiveness of Activity of the Local Self Government Agencies of City Okrugs and Municipal Raions.

By analogy with estimating the effectiveness of activity of the government bodies of the Federations subjects, this Edict establishes the list of indicators for estimating effectiveness, including financial indicators, indicators of efficacy, and also indicators of progress in promoting institutional reforms. It should be noted that the established list of indicators adequately matches the volume of powers vested in local self government agencies, which is a clear merit of this document. At the same time, it has a number of significant drawbacks, largely inherent in the applied methodological approach to centralized estimation of the efficiency of bodies of power in general:

- the values of some of the indicators largely depend not on the efforts of local self government agencies, but on the objective situation which has emerged in a municipal formation (this is true of the indicators of mortality, of the development of small businesses, of the volume of housing construction, etc);

- the values of some of the indicators depend on the policy pursued not at the municipal level, but at the regional one (the share of municipal educational establishments switched over to normative per-capita financing; the share of municipal medical institutions which apply medico statistical standards, etc);

- the values of some indicators reflect (or, in any case must reflect) the activity of business and not of local authorities (the level of collection of utility payments, and a number of other indicators in the sphere of the housing and utilities complex); the inclusion of these indicators in the mechanism of estimation could be counterproductive with regard to promotion of institutional reforms;

- the indicators of satisfaction of the population are rather subjective.

Yet another serious shortcoming of the approach applied in this document is the introduction of virtual accountability of local self government agencies to the bodies of power of a subject of the Russian Federation. The heads of the local administrations of municipal raions and city okrugs are obliged to submit, to the regional level, reports containing both the achieved and the planned values of the effectiveness estimation indicators. At the same time, it is recommended to the subjects of the Federation that they should establish a list of additional indicators for estimating the effectiveness of the activity of local self government agencies. In practice, such approaches could further restrict the autonomy of local self government agencies and increase their political and economic dependence on regional authorities.

Health Care: Fulfillment of Pilot Project on Regions S. Shishkin Starting with July 2007 a new pilot project has been fulfilled in 19 regions of the Russian Federation/ It is aimed at the increase of services quality in the field of health care. Variants of single-channel financing organization, ways to build-up tariffs in Compulsory Health Insurance system, holding of funds at the primary health care, system of health care employees labor remuneration, personalized accounting of health care volumes measures suggested by the very regions - are being tested. Project should come to the end in June 2008, but its results will obviously be insufficient to choose an effective model of health care system.

The task of health care system development is one of the key priorities of the modern government policy.

This position of the countrys political government was emphasized more than once in D. A. Medvedevs speeches. It was formulated in detail at the meeting on the health care and social insurance systems devel In his speech at a session of the Odintsovo Raion Council of Deputies, the head of the Raion, A. Gladyshev, made the following statement: There is no point in carrying out voting in Odintsovo Raion with regard to the issue of merger in the nearest future there will emerge a different procedure for merger into city okrugs // Vorota stolitsy (The gates of the Capital), 10. 04. 2008.

opment issues, which took place on 16 April 2008.43 The task is set to create effective health care model and it is expected that its solution will be aided by the results of the pilot projects fulfillment in the regions, which started in July 2007.

The main principles of this projects fulfillment and the list of the regions taking part in it were defined by the Decree of the Government of the Russian Federation on 19 May 2007 No 296 On establishing the rules of financing of the pilot project aimed at the increase of services quality in the field of the health care in the subjects of the Russian Federation The following were defined as the directions for the pilot projects fulfillment:

- Step-by-step transfer to predominantly single-channel financing of health care institutions through CHI system;

- Securing of hospital health care financing in accordance with the financial expenses norms that are calculated on the basis of health care standards, taking into account the quality of the health care rendered;

- Partial accumulation of funds intended to pay for health care rendering on the basis of per capita financing at the level of out-patients clinics (partial funds holding) and creation of intra- and interdepartmental transfers;

- Medical employees labor remuneration depending on the results of their work;

- Securing of personified accounting of the health care rendered in the system of compulsory health insurance and estimation of its quality.

There are 19 subjects of the Russian Federation that take part in the projects fulfillment: Astrakhan, Belgorod, Vladimir, Vologda, Kaliningrad, Kaluga oblasts, Krasnodar krai, Leningrad oblast, Republic of Chuvashia, Tver, Tomsk oblasts, Republic of Tatarstan, Rostov oblast, Perm krai, Samara, Sverdlovsk, Tyumenoblasts, Khabarovsk krai, Khanty-Mansi autonomous area. According to the conditions of the experiment, all five directions of the reforms are being fulfilled in 9 of the regions, in other regions 2 or 3 directions are being fulfilled (see table 1).

Table Directions of Reforms in the Subjects of the Russian Federation, Participating in the Pilot Project Subjects of the Russian Directions of reforms Federation 1 2 3 4 Single-channel Financing on Funds holding Labor remu- Personified financing the basis of at out-patients neration refor- accounting of through the health care clinics and mation health care CHI system standards wards rendered Belgorod oblast Vladimir oblast Vologda oblast Kaliningrad oblast Kaluga oblast Leningrad oblast Tomsk oblast Republic of Chuvashia Khabarovsk krai Astrakhan oblast Krasnodar krai Perm krai Republic of Tatarstan Rostov oblast Samara oblast Sverdlovsk oblast Tver oblast Tyumen oblast Khanty-Mansi autonomous area Total 12 13 10 13 Source: data of the Ministry for Health Care and Social Development http://www.rost.ru/official/2008/04/160000_13708.shtml RUR 2.5 bln was allocated from the Federal Fund of the Compulsory Health Insurance Federal Fund at the expense of assignments from the federal budget. In 2008 the planned expenses will be equal to RUR 2.bln.

Transfer to single-channel financing is being tested in 12 regions out of 19. Leading regions in this process are Tyumen oblast (share of government financing of the health care, accumulated in the territorys system of the CHI was, as a result of 2007, equal to 89%), Tomsk oblast (68%), Perm krai (66%), Vladimir and Kaliningrad oblasts (by 60%).

According to the general rule, the tariffs in the existing system of Compulsory Health Insurance compensate for 5 kinds of expenses of health care institutions: wages, additional sums of wages, medicines and inventory purchase, expenses for patients board. Within the framework of the pilot project the application of six extended tariffs, compensating for a wider range of expenses, is being testes. In Vladimir and Kaluga oblasts, Perm krai and Republic of Chuvashia expenses for utilities and for maintenance of health care institutions property are included in the tariffs. In Tomsk region the tariffs for payment for services and in Kaliningrad region per capita standards include expenses for thorough repairs and purchase of medical equipment, that is full tariff is applied.

Introduction of health care standards in the mechanisms of the health care institutions financing is being tested in 13 regions. However this process faced resources limitations. Out of 617 developed and approved standards for health care rendering more than a half (310) refer to the standards of highly-tech health care rendering. According to calculations made in a number of pilot regions payments for health care services in accordance with standards would require the increase of expenditures by2 to four times. Although this estimation refers to the standards of high-tech health care rendering, it creates a barrier to standards implementation. Pilot regions decided to implement standards selectively to calculate the amount of financing for some illnesses (from 4 to 21 in number) and independent development of standards.

Within the framework of the third component of the pilot project only the variants of intraeconomic transfers between the departments of the out-patients clinics are being tested in 9 out of 10 subjects of the Russian Federation. District doctors are stimulated by economic measures to increase the volumes and quality of the health services rendered and to decrease the number of patients sent to specialist doctors and to hospitals.

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