According to the existing quantitative estimates, the proportion of state-owned Russian companies amounted to 29.6% in 2006, and to 35.1% in early 2007. By the beginning of 2008, “the depth of property concentration” in the hands of the State within the Expert-400 base amounted to approximately 40-45%. If the degree of capitalization of the Russian market in mid-October 2008 is taken as the reference point, it can be forecasted, by way of applying simplest estimates, that the state’s share will be increased, in 2008-09, by 3-4 to 9-10 pp (without taking into account the possible transfer of shares to the State within the framework of refinancing procedures and the activity of state corporations in the strict sense of the word).
At the same time (all other factors being the same, including the political and corruption ones), the qualitative threshold of such an expansion is sufficiently evident: the bigger the state sector is, the more limited are the possibilities for efficient management and control. This is evidenced in particular by the whole experience of introduction (or attempts at introduction) of some or other new mechanisms of management and supervision for unitary enterprises and joint – stock companies with state stakes in the late 1990s – 2000s. By analogy with the evolution of Russian private business groups of the second half of the 1990s – early 2000s32, we have the reason to expect that in the mid-term perspective the authorities would introduce some or other reorganization procedures aimed at optimizing the structure of the acquired assets and the organizational and managerial aspects of functioning of state companies (or groups). Because of the 2008 financial crisis, this process could be intensified in connection with the fact that both state-owned and private companies urgently need to attract financial resources by way of getting rid of a number of assets which are not directly related to their basic activity.
According to estimates, although no less than 1 billion USD was spent in one week, from October 17 to 24, 2008, shares in those companies that the authorities were trying to bail out continued to fall, slumping by 15 to 33%. At the very least, this means a direct loss of state funds, although in the short-term perspective the fall of shares would have been stronger, had the state interventions not taken place.
Also put on the secret list, or at least difficult to access, despite the fact that by the end of 2008 more than a year had passed since the adoption of the key decisions, are the data on the investment of the funds received by state corporations (what is meant here is the organizational – legal form in the strict sense of this term) from the budget and the Stabilization Fund. The declassification of these data would be especially welcome in the present conditions of the 2008 financial crisis, bearing in mind that, in accordance of the normative-legal acts concerning the creation of state corporations, a considerable proportion of the above funds should be invested in securities.
See, for example, A. D. Radygin. Stabil’nost’ ili stagnatsiia Dolgosrochnye institutsional’nye problemy razvitiia rossiiskoi ekonomiki (Stability or stagnation the long – term problems of development of the Russian economy). / Ekonomicheskaia politika (Economic policy). 2007. No 1 (5). P. 23 – 47.
See, for example, A. Radygin. Evoliutsiia form integratsii i upravlencheskikh modelei: opyt krupnykh rossiiskikh korporatsii i grupp (The evolution of the forms of integration and the forms of control models: the experience of big Russian corporations and groups) / Rossiiskii zhurnal menedzhementa (The Russian journal of management). 2004. Vol. 2. No 4, October – December. Pp. 35 – 58.
How efficient these measures would be with regard to state companies and what motives would be behind such a reorganization – this will become evident in due course. Moreover, the quantitative growth of the State’s direct participation in the economy per se or the State’s persistently big share in the latter are by far unique in the contemporary world. The most urgent ones are the issues pertaining to quantitative assessments – primarily those concerning the coherence of the adopted strategy, as well as the targets (or motives) and long – term consequences (or costs) of this process.
The new Concept of the public health care system’s development S. Shishkin The RF Ministry of Health Care and Social Development and the RF Ministry for Economic Development have prepared documents determining the priorities of the government policy in the sphere of the public health care. However, there is a risk that they may remain a symbol of a performed ritual, rather than become an instrument for reforming the health care sector.
In the year of the presidential election the federal bodies of authority dramatically intensified their activity aimed at developing the goals for government policy in the sphere of the public health care system. In February 2008, the RF Ministry of Health Care and Social Development created a large commission for the purpose of mapping the Concept of the public health care system’s development until the year 2020. For discussing the project a special website was opened (http://www.zdravo2020.ru/), where anyone can now submit his or her proposals as to the content of the future concept. As of the end of October 2008, this website received approximately 600 proposals and more than 2,200 commentaries to those proposals. It is necessary to note that this has been the first experience of organizing a large-scale public discussion of the future concept. No doubt, it represents an important step in the formation of new democratic institutions of state administration. However, unfortunately, the results of this innovation have been found to be nearly zero. Evidently, the Ministry lacked the resources necessary for analyzing this multitude of proposals and producing a comprehensive summary document on their basis. Initially it was declared that the draft of the concept would be prepared in May, but so far it has failed to materialize.
Instead of the concept’s draft, the RF Ministry of health care and social development issued, in July 2008, a rather short document entitled “The Main Directions of the Concept of the Public Health Care System’s Development Until the Year 2020”. Simultaneously, the government continued to work on the draft of the Concept of long-term socioeconomic development of the Russian Federation in the period until the year 2020. The latest version was published by the RF Ministry for Economic Development in October (http://www.economy.gov.ru/wps/wcm/myconnect/economylib/mert/ resources/3879cd804ab8615ab426fc4234375027/kdr_15_10_08_itog.doc). The Section “Development of the the public health care system” of that version contains so far the most detailed and wellsubstantiated description of the suggested government policy priorities in the sphere of public health care.
The first priority goals, within the framework of this policy, are as follows:
• to ensure government guarantees of free-of-charge comprehensive medical care to RF citizens, including the statement in precise terms and consolidation in legislation of the types, volumes, procedures and terms for providing free-of-charge medical services, etc.;
• to create an effective model for generating the funds necessary to finance the program of government guarantees, including the switchover to one-channel funding of medical care on the basis of compulsory medical insurance (CMI), and the establishment of federal standards for the size of contributions to be paid by subjects of the Russian Federation to cover the compulsory medical insurance of non-working population;
• to modernize the CMI system, including the formation of an alternative competing CMI system where the insurer and the medical institution can be chosen by the insured person, etc.;
• to improve the efficiency of the system for organizing the provision of medical care;
• to improve the supply of pharmaceuticals to RF citizens on an outpatient basis, including better access of citizens to selecting appropriate pharmaceuticals within the framework of outpatient care, by combining the government programs for the supply of pharmaceuticals with medical insurance of citizens;
• to ensure computerization of the public health care system;
• to create a system for protecting the population’s health;
• to implement the Priority National Project “Health” (2009 – 2012).
These goals on the whole correspond to the problems currently faced by the public health care system. The suggested directions for introducing the institutional improvements needed for achieving these goals also appear to be generally well-substantiated. However, there are no indications as to which methods should be applied in achieving some of these goals, or these indications are too generalized.
The goal of specifying these government guarantees is, quire reasonably, characterized as the first priority. In the draft document’s previous versions it was suggested that this goal should be achieved by means of developing and approving the medico – economic standards of care to be administered for specific health conditions. This approach seems to be correct, but in the latest version there is no mention at all of any approach to specifying such guarantees.
For a long time already there has been a need for creating a system for providing RF citizens with pharmaceuticals on the basis of a combination of the government programs for the supply of pharmaceuticals with medical insurance of citizens, but it should be determined more precisely how these two mechanisms are to be combined, and which categories of citizens they are going to cover.
The document, quite justifiably, points to the necessity of increasing the economic independence of medical institutions, but says nothing as to any policy aimed at changing the existing organizational and legal forms of medical institutions (presently the law does not allow any transformation of budget-funded institutions belonging to the public health care system into autonomous institutions). Regretfully, the document offers no well-formed standpoint with regard to certain important issues, such as the provision of medical services on a commercial basis by state and municipal medical institutions, or the development of a non-government system for providing medical care.
Document keeps silence concerning the issues of organization of work and remuneration in the public health care system. Probably it is believed that the already adopted decisions as to the introduction, from the year 2008 onwards, of a new by-branch system of remuneration have provided a sufficient solution to the problem. One can hardly accept such an approach.
Reform of the remuneration mechanisms in the public health care system cannot be reduced to one-time actions like raising certain categories of salaries, as is envisaged in the National Project, and to introducing a new by-branch system of remuneration. There is obviously a need for a longterm strategy of actions in the sphere.
The draft document says nothing concerning the existing gross structural disproportions in the system of providing medical care (insufficient development of primary medical and sanitary care, the dominant role of inpatient institutions in the system, a high percentage of unjustified hospitalizations, and other similar phenomena). For the past ten years the government, in its program documents, has been setting the goals of restructuring the public health care system, of the first priority development of primary medical and sanitary care, of improving its effectiveness by introducing the institutions of a physician - general practitioner, of developing day-care establishments, and of reducing the scope of excessive round-the-clock inpatient care. There is no mention, either, of any of the aforesaid goals, or of the reasons for the slow progress in their achievement. The directions of the structural changes in the organization of inpatient and outpatient medical care should be determined in more detail.
The declared priorities have failed to adequately reflect the existing problem of substantial inequality in the distribution of the burden of costs within the public health care system between groups with different levels of income (the poor being obliged to spend a large proportion of their available resources on medical care) and the pronounced differences in the availability of medical care to residents of different types of municipalities (those residing in villages and small towns have less opportunities for receiving specialized outpatient care), or to employed citizens as compared to pensioners (the latter having comparatively less opportunities for screening and have to spend more time on waiting lists prior to hospitalization).
The conceptual proposals prepared by the government in regard to the development of the public health care system have so far been of a too general character, and there is a risk that their fate may be similar to that of all the earlier documents of the same type - that they will remain a token of a performed ritual, rather than become an instrument for actual reform.
However, the draft of the Government Program of the Public Health Care System’s Development in the period of 2009 – 2012, prepared and issued by the RF Ministry of Health Care and Social Development in September 2008, has no such limitations. This document contains detailed proposals concerning the measures to be financed in the next three years from the federal budget - in the amount of 628 billion rubles, and from government off-budget funds - in the amount of 111 billion rubles. The Program’s priority directions are as follows:
• provision of hi-tech medical care to the population;
• improvement of the cardiovascular medical care;
• improvement of the medical care for victims of traffic accidents;
• improvement of the organization of medical care for cancer patients;
• measures aimed at developing the blood products supply service, and other subprograms.
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