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Implementation of the Government Guarantees Program in In 2006 the differences in the financial support of the Program approved by Federal Government Resolution No 461 revealed themselves even more strikingly in connection with a further unequal economic development in the regions of Russia and the launch of the First Priority Health Project which has been implemented with varying success in various regions.

Following the 2006 Program implementation results, the overall regional funding was estimated at Data for 2004. Source: Indicators of Science, Statistical collection. M. GU-VShE, 2006, p. 117. .

. .: -, 2006, .117.

The total needs of the Program for 2000 2005 inclusively are estimated as the permanent population size in Russia times the indexed size of the per capita funding norm.

The calculation is made in compliance with the laws of the regions on the implementation of the regional budgets under budget item 09 01 Health Service. The report of the Ministry of Health and Social Development of Russia shows the amount of actual costs for the Program - 470.2; this includes additional federal budget funds designated for the implementation of a set of actions under this Program.

Here the data for 10 subjects of the Russian Federation only are shown in the Tables; however the author reviewed all of them during the survey.

This is an authors estimate; according to the Ministry this figure is 34.

RUR723 billion including RUR273 billion supplied through CMI channels; this makes 128% and 85% of the estimated Program and CMI Basic program needs, accordingly, in line with the approved per capita norms in the RF Government Resolution No 461 (Table 4). In spite of the general growth of funds for the public health service, the situation remains controversial in various regions. The variation coefficient for 10 subjects of the Russian Federation was 1.05 compared to 0.85 in 2005. In 2006 the regional Moscow Program funding support will be at 327% and in St.-Petersburg at 254%.

It is worth mentioning that equalization of funds for the regional programs occurs via two channels: the CMI Equalization Fund (RUR33.2 billion in 2006; around RUR29 billion in 2005) and intergovernmental equalization by the Ministry of Finance. However, these two methods are not consistent, and this does not allow for effective equalization of the regional financial possibilities in the health area.

Thus, in 2006 the Program estimated funding norm proved to be lower than the actual costs in the majority of the regions; however, there is no mechanism of limiting growth of expenses for the health services in the dynamically developing regions to equalize costs.

The Prospects of Implementation of the Government Guarantees Program in According to item 2 of the Federal Government Resolution No 461 of 28.07.2005, the Ministry of Health and Social Development of Russia is to introduce, by July 1, 2006, to the RF Government, under the established procedure, a draft Government Guarantees Program for Providing Free Medical Care to the Russians for 2007. However, regardless of the established dates and the proposed deadline for approving the Government Guarantees Program for 2007 which is the 1st of December, the Program has not been ready. Instead the federal Compulsory Medical Insurance Fund circulated in the regions a letter of August 11, No 5893/26-I On the Draft Government Guarantees Program for Providing Free Medical Care to the Russians for 2007 where per capita funding norms of RUR4670.4 (under the Program) and RUR2334.7 from the CMI fund were shown. Compared to 2006 the funding norm growth was 28.2%, and this relates to the changes in the normative rate calculation procedure.

The basic change in the calculation was the account of the wage growth in the health service which in the health cost structure accounts for 70% - 80%. Another reason for the delay in the official publication of the Program is that the Ministry of Health and Social Development reviews an option of including into the Program of Government Guarantees a program of additional medicine provision. This would require cardinal changes in the approaches to the estimates of the program financial model.

Thus the Program presently is losing its status as a benchmark for shaping regional budgets; it is still a reference point for the CMI Fund which share in financing remains insufficient to cover all 5 protected items not mentioning the transition to a 100% insurance principle. This shapes the need to modify the calculation method of the federal normative rate of funding under the Government Guarantees Program as well as regional rates with account of actual factors that objectively affect the funding needs of the regional health care systems.

Main Trends of Upgrading the Calculation Method of the Need to Finance the Government Guarantees Program The main problems associated with the development and implementation of the Government Guarantees Program are stated below:

- Reduction of the Program regulating function in the formation and financial justification of the regional government guarantees programs;

- The federal executive authorities lack the possibility to plan the health development at the national scale;

- Inconsistency of the equalization policy implemented by the CMI Fund and the Ministry of Finance in leveling budget funds;

- Delays in the official publication of the Program for planning health resources;

- Absence of transparency in calculation of the federal per capita financing norm of the Program and therefore a possibility to play with the figures based on the macro-economic budget restriction but not the objective factors;

- Increasing differentiation in regional health financing, which makes the existing disproportion even larger;

- No limitations in funding capital expenditures from all government budgets;

- Incomplete per capita financing norm for CMI;

Table 1. Government Guarantees Program (GGP) needs in 2005 and the actual implementation of the Program in 10 subjects of Russia GGP needs in 2005, in RUR million Actual funding in 2005, in RUR million Implementa Imple- ImpleAdjusted tion/to men- mennormative CMI tal tation/ tation/ rate for normaConsolidated Consolidated Budgets of ratio GGP in tive rate budget of a RF budget of a RF CMI Re- in % budge CMI 2005 in in 2005, subject for health CMI needs subject for health gional t ratio ratio Region RUR in RUR Total care in 2005 Total care Funds in %. in % Russian Federation 3 693,69 1 507,50 529 984,00 228 827,35 301 156,65 451 061,37 234 574,75 216 486,62 85% 103% 72% 1 North Ossetia republic 3 242,24 1 548,20 2 283,83 986,07 1 297,76 1 040,88 421,75 619,14 46% 43% 48% 2 Tambov region 3 157,00 1 507,50 3 614,13 1 560,45 2 053,69 1 779,93 529,64 1 250,29 49% 34% 61% 3 Kaliningrad region 3 157,00 1 507,50 2 983,37 1 288,11 1 695,26 1 513,20 461,32 1 051,89 51% 36% 62% 4 Khabarov region 5 180,64 2 473,81 7 357,54 3 176,71 4 180,83 5 854,01 2 930,15 2 923,86 80% 92% 70% 5 Belgorod region 3 157,00 1 507,50 4 772,12 2 060,42 2 711,70 3 800,36 1 895,30 1 905,06 80% 92% 70% 6 Sverdlovsk region 3 636,86 1 736,64 16 104,76 6 953,44 9 151,33 12 829,97 6 234,18 6 595,79 80% 90% 72% 7 Samara region 3 157,00 1 507,50 10 106,50 4 363,61 5 742,89 8 078,60 4 153,52 3 925,09 80% 95% 68% 8 Moscow 3 157,00 1 507,50 32 853,64 14 184,98 18 668,66 66 385,09 42 071,60 24 313,49 202% 297% 130% 9 St.-Petersburg 3 157,00 1 507,50 14 522,20 6 270,15 8 252,06 30 583,36 22 651,64 7 931,71 211% 361% 96% 10 Chukotka Autonomous Okrug 9 471,00 4 522,50 480,18 207,32 272,86 1 532,05 933,70 598,35 319% 450% 219% Table 2. RF subjects where the actual implementation of the Program in 2005 exceeded the estimated needs GGP needs in 2005, in RUR million Actual funding in 2005, in RUR million Adjusted Imple- Implenorma- CMI Imple- menta- mentative rate normaConsolidated Consolidated Budgets of menta- tion/ tion/ for GGP tive rate budget of a RF budget of a RF CMI Re- tion/total budget CMI in 2005 in in 2005, subject for health CMI needs in subject for health gional ratio in ratio in ratio in Region RUR in RUR Total care 2005 Total care Funds % %. % Russian Federation 3 693,69 1 507,50 530 397,51 229 005,89 301 391,62 451 653,70 234 979,70 216 674,00 85% 103% 72% 1 Yaroslavl region 3 157,00 1 507,50 4 226,28 1 824,75 2 401,53 4 334,41 2 139,94 2 194,47 103% 117% 91% 2 Kaluga region 3 157,00 1 507,50 3 224,88 1 392,38 1 832,49 3 737,34 2 277,00 1 460,34 116% 164% 80% 3 Lipetsk region 3 157,00 1 507,50 3 756,51 1 621,92 2 134,59 4 689,99 2 662,22 2 027,77 125% 164% 95% 4 Moscow 3 157,00 1 507,50 32 853,64 14 184,98 18 668,66 66 385,09 42 071,60 24 313,49 202% 297% 130% 5 St.-Petersburg 3 157,00 1 507,50 14 522,20 6 270,15 8 252,06 30 583,36 22 651,64 7 931,71 211% 361% 96% 6 Taimyr Autonomous Okrug 7 576,80 3 618,00 298,53 128,89 169,63 643,54 407,07 236,47 216% 316% 139% 7 Nenetsk Autonomous Okrug 7 261,10 3 467,25 304,63 131,53 173,10 670,31 539,31 131,00 220% 410% 76% 8 Chukotka Aut. Okrug 9 471,00 4 522,50 480,18 207,32 272,86 1 532,05 933,70 598,35 319% 450% 219% 9 Evenkia Aut. Okrug 7 576,80 3 618,00 131,84 56,92 74,91 358,47 319,53 38,95 272% 561% 52% Table 3. RF subjects where the actual implementation of the Program in 2005 was less than 50% of the needs GGP needs in 2005, in RUR million Actual funding in 2005, in RUR million.

Adjusted Imple- Implenormative CMI menta- mentarate for normaConsolidated Consolidated Budgets of Imple- tion/ tion/ GGP in tive rate budget of a RF budget of a RF CMI Re- menta- budget CMI 2005 in in 2005, subject for CMI needs in subject for gional tion/total ratio in ratio in Region RUR. in RUR Total health care 2005 Total health care Funds ratio in % %. % Russian Federation 3 693,69 1 507,50 530 397,51 229 005,89 301 391,62 451 653,70 234 979,70 216 674,00 85% 103% 72% 1 Republic of Tuva 6 080,38 2 903,45 1 870,33 807,54 1 062,79 448,55 16,79 431,76 24% 2% 41% 2 Republic of Chechnya 3 157,00 1 507,50 3 603,08 1 555,68 2 047,41 925,38 622,27 303,11 26% 40% 15% 3 Republic of Ingushetia 3 157,00 1 507,50 1 520,41 656,46 863,95 561,97 263,31 298,66 37% 40% 35% 4 Republic of North Ossetia 3 242,24 1 548,20 2 283,83 986,07 1 297,76 1 040,88 421,75 619,14 46% 43% 48% 5 Tambov region 3 157,00 1 507,50 3 614,13 1 560,45 2 053,69 1 779,93 529,64 1 250,29 49% 34% 61% Table 4. GGP needs in 2006 and approved amounts of funding in 10 RF subjects GGP needs in 2006, in RUR million. Approved funding in 2006 in RUR million Consolidated Implebudget of a RF mentasubject for health Budgets of Implemen- tion/ care in 2006 Consolidated budget CMI Re- Implemen- tation/ CMI of a RF subject for gional tation/total budget ratio in Region Total CMI needs in 2006 Total health care in 2006 Funds ratio in % ratio in %. % Russian Federation 567 084,56 244 851,94 322 232,62 723 187,20 450 000,00 273 187,20 128% 184% 85% 1 Republic of North Ossetia 2 443,71 1 055,13 1 388,58 2 456,73 1 185,00 1 271,73 101% 112% 92% 2 Tambov region 3 867,13 1 669,73 2 197,41 3 300,14 1 487,79 1 812,35 85% 89% 82% 3 Kaliningrad region 3 192,21 1 378,31 1 813,90 2 032,07 661,38 1 370,70 64% 48% 76% 4 Khabarov krai 7 872,59 3 399,17 4 473,42 7 057,85 3 263,75 3 794,10 90% 96% 85% 5 Belgorod region 5 106,18 2 204,71 2 901,47 4 869,65 2 686,83 2 182,82 95% 122% 75% 6 Sverdlovsk region 17 232,15 7 440,38 9 791,77 18 336,58 9 762,92 8 573,66 106% 131% 88% 7 Samara region 10 813,99 4 669,19 6 144,80 10 334,40 4 827,56 5 506,84 96% 103% 90% 8 Moscow 35 153,49 15 178,34 19 975,16 114 795,27 74 826,37 39 968,90 327% 493% 200% 9 St.-Petersburg 15 538,80 6 709,24 8 829,56 39 524,21 30 107,98 9 416,22 254% 449% 107% Chukotka Autonomous Ok10 rug 513,79 221,84 291,95 1 621,65 1 076,41 545,24 316% 485% 187% The key areas of work to address the said problems are as follows:

1. Modernization of the calculation method of the Program funding needs with account of factors accounting for a sharp growth of differentiation in the amount of health expenditures;

2. Development of mechanisms that would fix the minimal funding norms compulsory for compliance by the RF subjects (stimuli to meet the minimal norms);

3. Formation of a single mechanism of equalization in the RF health care system using CMI Fund and the Regional Equalization Fund of the Ministry of Finance;

4. Bringing the financial norms close to standards of medical care provision; calculation of the Program needs based on those standards;

Inclusion in the methodology of tools limiting health expenditures (for capex);

. New Amendments to the Legislation on Delineation of Powers Between Local Authorities In the recent years, a tradition came into being to adopt at the end of December new legal regulations on amendments to delineation of powers between different levels of local administration authorities. Such a tradition can not be regarded as positive one. The amendments are introduced at the time, when the budgets for the next year are approved, the administration structures are formed (together with relevant staffing budgets), and there is a certain vision of the local administrations activities for the nearest future. The amendments to delineation of powers bring confusion and require revisions to management system, budget adjustment, they make more complicated the contracting procedures on delineation of powers from communities to municipalities and vice versa. Nevertheless, in December 2006 again a new legislation is introduced on amendments to some laws of the Russian Federation for the purpose of enhancement of delineation of powers. The draft law is already approved by the Federal Council and is submitted for authorization of the RF President.

The new legislation is basically aimed at delineation of powers between the Federal level and the Subjects of the Federation, though it involves the activities of local administration authorities as well. In regard to the latter authorities, the new amendments can be joined in two groups: those, which put in order and sort out earlier introduced amendments and those, which immediately affect the competence areas of local authorities.

The new amendments bring in rather complicated and inconsistent system of competence of the local authorities, including:

Settlement of the issues of local significance;

Execution of responsibilities, transferred from federal level;

Participation in execution of other responsibilities, in case it is foreseen by the federal legislation;

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