Defining federal bodies’ goals by way of finding measurable com ponents of the general socio economic development objectives should be excluded from the budget process. The use of such measurable components is justified in the form of indicators for goals achievement but not in the form of target indices designed to performance measurement of the government bodies, which is done in the framework of the budget process.
Increasing the number of levels for the goals specification in order to guarantee gradual transition from the general goals to goals and objectives, achievement of which correspond to every government body’s capacity.
Formulate qualitative and quantitative characteristics, which allow judging about the level of goals achievement only regarding spe cific tasks and agencies performance programs.
Provide comprehensive description of target programs, which characterize used mechanisms aimed at the achievement of cor responding tasks.
In any case, it is obvious that transition from the current system of budget planning to performance based budgeting arrangement re quires a prolonged period of adaptation. At the same time, develop ment of the performance measures system, which at present comes to the forefront, should not be the essence of this process. Main attention should be paid to the development of the system of goals and objec tives of their achievement and separation of the types of activity, which link resolution of tasks with the require volume of resources needed for the achievement of specific outcomes.
4. Principal Venues of the Reform In Individual Branches of the Budget Sector 4.1. Health Care 4.1.1. Venues of restructuring of the public health care institutions’ network Despite the rise in volumes of financing of the health care sector since 2000, there presently exists a considerable gap between public guarantees of medical assistance and their financing. To bridge the gap requires a comprehensive reform of the health care system. Its major avenues were stipulated in the 2003 and 2004 presidential Addresses to the Federal Assembly of RF110 and program documents of the RF Gov ernment (particularly the Program of socio economic development of the Russian Federation for the medium term perspective (2005)111.
One of the reform avenues implies specification of the package of medical and diagnostic services and medicines guaranteed to citizens of RF at the expense of tax sources and within medical standards by each kind of illness. The package in question should be equal for all the citizens of the country, while a complementary medical assistance be yond the package is provided against co payments for it by employers and the population. The government, in turn, should carry out a number of preventive measures and treatment of socially perilous diseases.
In addition, the government documents set the task of moderniza tion of the Compulsory Medical Insurance (CMI) system through:
- Legislative setting of a uniform principle of computation of the non working population's contributions to CMI;
- Securing participation of the “federal level” in co financing, to gether with the RF Subjects the non working population's contribu tions to CMI;
See: The Address of the RF President to the Federal Assembly of RF on 16 May and Address of the RF President to the Federal Assembly of RF on 26 May 2004.
Decree of the RF Government of 15 August 2003 No. 1163 r “On Approval of the Pro gram of Socio Economic Development of the Russian Federation for Medium Term Per spective (2003–2005)”.
- Introducing a minimum amount of the insurance premium for medi cal insurance of an employee;
- Accomplishing the transition to the system of a single payer for medical services provided at the government's expense, by con centrating the main part of budget resources in the CMI funds in the form of contributions for non working citizens;
- Accomplishing the transition to funding medical institutions on the basis of full rate tariffs that include all kinds of costs of medical assistance.
Yet another cause for the existence of the gap between the public guarantees of medical assistance and their financial provision lies with an inefficient resource management in the therapeutic and preventive care institutions. To solve this problem necessitates a re profiling or a complete withdrawal out of the public health care system of a part of financially unsecured and inefficiently used therapeutic and preventive care capacities. That is why the budget network restructuring forms a key avenue for the Russian health care system reform.
The restructuring of the system of provision of medical assistance implies the employment of the following mechanisms:
- Modification of the medical institutions' organizational and legal form;
- Replacement of the estimate based funding with compensations for the quantity and quality of delivered medical services; introduc tion of new forms of labour compensations to medical personnel that should orient them towards increasing the volume and quality of medical assistance, and focus of medical institutions' operations on preventive care work;
- Modification of methods of planning of budget expenditures on health care;
- Design of territorial restructuring programs.
The present section deals with analysis of prospects for implemen tation of the restructuring along two major avenues: namely, optimiza tion of the budget network and introduction of new organizational and legal forms for health care institutions. The main avenues for the health care system restructuring are considered in a greater detail below.
4.1.2. Optimization of the health care institutions network This particular avenue for optimization of the health care institutions network implies the following actions that are not associated with the introduction of new organizational and legal forms: that is, assigning a part of the federal health care institutions to the regional and local lev els, assigning departmental health care institutions under control of profile managers of budget funds, and re allocating capacities and re sources between the in patient and outpatient sectors. Let us consider each action in more details.
The principles of optimization of the network of federal public institu tions were set in the Procedures of organization of work on optimization of the budget network approved by the Governmental Commission on Administrative Reform112. According to the document, to retain an insti tution as the federal property necessitates observance with one of the following conditions:
a) Products and services produced/supplied by the institutions ap pear necessary for:
- Securing the exercising of powers of federal government bodies of power as per the federal law, government and presidential acts;
- Provision for free or at a price regulated by government agencies (in the areas of health care, education, social security and other ar eas, as per the federal law);
- Forming their stock that cannot be procured from non governmental organizations at the expense of the federal budget funds.
b) The Institution exercises:
- Special functions with respect to ensuring the national security and other strategic interests of the Russian Federation (for instance, it designs and produces items that ensure security of the Russian Federation);
- Manufacturing of kinds of products that are withdrawn from the civil turnover or the usage of which in the civil turnover is limited;
The procedures of organization of the work on optimization of the network of subordi nate to the federal bodies of executive power general unitary enterprises, federal public institutions, as well as stock (shares) packages in the federal property. Minutes of the Government Commission on Administrative Reform’s meeting of July 13, 2004, No. 18.
- Provision of services to federal civil servants, unless the services may be procured from non government institutions, due to the ne cessity of ensuring security or maintaining provision of guarantees of provision of the respective services to the noted individuals.
Accordingly, it is suggested to transfer institutions from the federal property under the ownership of Subjects of RF and municipal entities in the event the services they produce are necessary for ensuring the exercising of powers of the RF Subjects’ government bodies and local self governance bodies set by federal laws and the noted services have to be provided free of cost or at a regulated price, but they may not be procured by regional and local budgets from non governmental organi zations.
It appears that the noted criteria are insufficient to ensure a sound decision making on the transfer of federal institutions to the regional and local levels. More specifically, as far as the health care sector is concerned, it is appropriate to use the "population coverage" criteria, thus assessing the appropriateness of the transfer depending on whether a given institution renders services to the population of the Russian Federation by large, a Subject of RF, or an individual municipal entity.
As noted in the section on the analysis of the contemporary situation in the health care sector, 37% of all the federal institutions that currently operate in this area are controlled by non profile main managers of budget resources. At this juncture, it is possible to propose several op tions of restructuring of health care institutions that fail to fall under the main budget managers’ profile:
1. Assignment of all the non profile health care institutions (except for those under the Ministry of Defence and law enforcement agencies) under control of the Federal Agency for Health Care and Social Devel opment.
The advantage of this option is that such an arrangement would match the principles of the administrative reform: all the public health care institutions would fall under the purview of the agency whose effi ciency is measured by the nation's health indicators.
2. Transformation of every non profile health care institution into a new organizational and legal form – that is, PANO, while it retains its departmental subordination.
The advantage of this option is that there would arise a competition between networks of health care organizations that would belong to different agencies. An indirect result of the existence of such “duplicat ing” networks would become simplification of such a performance based governance technique as benchmarking.
3. With its Resolution, the RF Government, upon conciliation with main managers of budget funds that control non profile health care in stitutions, would approve a list of institutions subject to the mandatory transfer under control of the Federal Agency for Health Care and Social Development. According to the decision of the main manager of budget funds other non profile medical institutions can be retained under its control, provided they are transformed into PANOs, or re assigned to the Federal Agency for Health Care and Social Development. This is an intermediate option.
A separate problem of organization of the budget network on the federal level is the one of existence of main managers of budget funds that are not government agencies. To exemplify that, the Russian Academy of Medical Sciences controls 41 specialized medical institu tions. It appears appropriate to transfer these institutions in their capac ity of recipients of budget funds under control of the Federal Agency for Health Care and Social Development.
According to the Consortium formed by ZAO "Yunikon/MS Consult ing Service" and the Centre for Economic and Social Research113, the liquidation of the departmental health care will enable one to ensure principles of social fairness, exclude the doubling of the per capita funding of medical assistance for individual categories of citizens, lower the social pressure on the agencies' budgets, facilitate accomplishment of the mission of financial equalization of territories' capacities, and, on the whole, ensure a more economical and rational consumption of re sources. According to the Consortium experts, the liquidation of the duplication of the public and departmental health care would allow a rational use of 25.6% of the federal budget funds currently allocated for the sector for health care.
Itogovy otchet po provedeniyu obzora budzhetnykh raskhodov na zdravookhranenie ot konsotsiuma v sostave ZAO "Yunikon/MS Consulting Service" and the Center for socio Economic Research. M., 2001.
As concerns the sub national level, the critical avenue of optimiza tion of the budget network is reallocation of capacities and resources between the inpatient and outpatient sectors, which includes, in particular:
- Transferring a part of volumes of medical assistance from the inpa tient to the outpatient stage;
- Getting rid of excessive hospitals, coupled with using a part of thus available facilities to provide medico social assistance;
- Liquidating a non rational consumption of medical services by means of regulation of procedures of delivery of medical assistance to the population and optimization of patients flows and the inpa tient medical care facilities network;
- Priority development of the primary medico sanitary assistance fol lowing the principle of general doctor practices;
- Gradual contracting of the overall number of doctors and modifying the structure of doctor corps in favour of the primary link doctors;
- Contracting of the number of unjustified hospitalizations;
- Shortening the term of treatment at inpatient medical care institu tions;
- Developing inpatient daily care medical institutions.
Experts have already evaluated possible effects from and risks as sociated with implementation of the noted measures on the regional level. Thus, the noted Consortium research emphasizes that should the measures on liquidation of the imbalances in the regional health care systems be liquidated and the volumes of provision of medical assis tance be reallocated from the costly and resource intensive assistance to the inpatient substituting one, as well as non profile hospitalizations be excluded, that would lower the need for the use of hospital bases 3– 4 times and allow a 1.5–2 fold saving of costs for the same volume of medical care activity.
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