Table Expenses for the Priority National Project in the Field of Public Health Care, as billions of RUR Branch of national project, types of expenses and sources of funds 2006 Federal budget Priority “Development of the primary medical care” Training and retraining of general practitioners (family doctors), district doc0.15 0.tors, district pediatricians Payments for general practitioners, district therapeutists, district pediatricians 14.6 21.and nurses who work with them Payments for medical personnel of first aid and obstetric stations, doctors, 4.1 11.medical assistants and nurses of ambulance Equipment of municipal outpatients’ clinics with diagnostic equipment 14.3 15.Equipment of emergency units and offices with ambulances 3.6 3.Population immunization 4.5 6.HIV prevention, population check-up in order to reveal people, infected with 2.8 7.hepatitis Â and Ñ, HIV, and their treatment Check-up of the new-born children for galactosemia, adrenogenital syndrome, 0.4 0.mucoviscidosis Priority «Provision of high-tech medical care for population” Construction of high-tech medical care centers 3.2 28.High-tech medical care rendering 9.8 17.Carrying out information support and project administration 0.6 0.Fulfillment of trail project on health care modernization - 6.Total from the federal budget 58.1 120.Means of Federal Fund for Compulsory Health Insurance Conducting of extra clinical examination of employees of a government1.6 4.financed organizations at the age of 35-55 years Extra payment for primary medical aid for pensioners who do not work (tariff increase within the limits of regional compulsory medical insurance programs 4.3 - by 25%) Total by FFCHI 5.9 4.Means of the Fund for Social Insurance o the Russian Federation Payments for medical aid for women in the period of pregnancy and childbirth 9.0 14.(“childbirth certificate”) Payment for additional clinic examination of the workers and primary medical 3.9 3.aid provided for them Additional medical check-ups of employees in the industries connected with 1.9 2.harmful and (or) dangerous factors of production Total by FSI RF 14.8 19.Total 78.9 143.Total, as percentage of the GDP 0.29 0.National project includes extra cash payments for the doctors of the primary health care (district physicians, pediatricians, general practitioners) and nurses who work with them at the rate of RUR 10000 and RUR 5000, correspondingly. Besides, payments for medical personnel of first aid and obstetric stations, doctors, medical assistants and nurses of the emergency were included in the project: RUR 5000 a month for doctors, RUR 3500 a month – for medical assistants (midwives) and 2500 a month - for nurses. As a result the wages of 690 thou of medical workers of the primary health care has increased by nearly 1.6 times over two years (by 250-300% for doctors and nurses and by 55% for medical assistants) and was equal to RUR 22600 for district physicians and RUR 15500 for medical officers in general.
The rates of payments and conditions for their receipt however were found to be independent of the work quality. According to the data of the Federal Service on Surveillance in Health Care and Social Development, no medical worker of the primary health care was deprived from the additional payments for ungrounded medicines prescription within the framework of additional medicines provision or for careless attitude for his duties.
The following real results of the increase in wages of doctors and nurses rendering primary health care that was made within the framework of the National project can be outlined:
• Growth of attractiveness of district therapeutists and pediatricians positions, partial filling of vacant positions; improvement of wages remuneration attracted 7.7 thou of doctors, more than 3000 of young specialists and the same number of the paramedics; district service ceased to have an acute shortage of staff;
• Increase in volume and intensity of district therapeutists and pediatricians work;
• Increase in labor remuneration was in fact the extra payment for work according to the program of additional supply with medicines of some categories of citizens that receive governmental support from the federal budget;
• Ambiguous effect on the work of district therapeutists and pediatricians:
o On the one hand due to liberation of a part of the work time, decrease in necessity to work somewhere else and consequently lower tiredness of doctors, they have opportunity to pay more attention to the patients;
o On the other hand fulfillment of extra medicines provision program and bigger amount of accounts for the measures of the National project increased considerably the form filling for medical personnel (according to some evidence up to one third of the work time district therapeutists spend writing prescriptions and filling forms) and, on the contrary, reduced the time given for other categories of patients;
• Negative influence on the work motivation of other categories of doctors that have not received such additional payments and consider the ratio of their wages and wages of district therapeutists as unfair.
The problem of shortage of staff at the primary health care has not been completely solved. Contrary to expectations, no t all vacant positions have been filled. The increase in wages was insufficient to increase the attractiveness of the work in the small towns and in the country. According to the data of the Federal Service on Surveillance in Health Care and Social Development, in 2006-more than 1500 first aid and obstetric stations were closed, which is the reduction by 3.6% due to the lack of medicinal personnel and discrepancy of the stations’ situation and licensing requirements.
Within the framework of the National project “Health” more than 42 thousand of articles of rontgenologic, laboratory, ultrasonic, endoscopic and electrocardiographs equipment were delivered to 10 thousand outpatients’ clinics of primary health care in 2006-2007. According to the Ministry of Health Care and Social Development of the Russian Federation data, the average waiting time for check-up in outpatients’ clinics, which received new equipment, reduced from 10 to 7 days. 13.2 thousand ambulances were supplied for emergency service, the fleet of ambulances having been renewed by 70%. According to estimations of the Ministry of Health Care and Social Development, the average period of waiting for emergency teams has reduced as a result from 35 to 25 minutes.
There is no doubt that these measures have improved material and technical equipment of the primary health care institutions and contributed into the increase in availability of primary, specialized outpatients’ and ambulance public health care. However inefficient spending of a part of the funds was unavoidable.
Presence of qualified specialists and sufficiency of room was not taken into consideration while supplying equipment to outpatients’ clinics. Proper account was not given to real demand of a clinic in equipment and local opportunities to purchase expensive consumables. Funds for consumables and equipment repair (there was some evidence that some of the equipment got broken having functioned less than a year) were not envisaged either in the National project or in the expenditures for fulfillment of territory compulsory health insurance programs fulfillment. Financing of these expenses depended on resources of local budgets. As a result there were many cases equipment stopping operating after spending of consumables sets supplied with it. According to the data of the Federal Service on Surveillance in Health Care and Social Development more than 3200 articles of equipment and pieces of machinery had been idle by the end of 2007 (5.8% of the total), that were supplied in 2006-2007 at the total sum of RUR 1.5 bln (4% of the expenditures of the National project for these aims).
Within the framework of the project 10.6 workers of the budgetary institutions and 7.4 mln of those engaged in the work with hazardous and (or) dangerous factors of production were clinically examined. The results of this part of the National project are however ambiguous. The payment for check-up of one person is envisaged to be RUR 540 – the sum that does not fully compensate the expenditures of a clinic. In order to conduct clinical examinations doctors were distracted from the consultations that increased the waiting lists for other categories of citizens and reduced the availability of outpatients’ clinic’s health care for them. The clinical check-up was not complete everywhere due to the absence of the necessary specialist doctors in the municipal clinics: according to the data of the Federal Service on Surveillance in Health Care and Social Development, more than in 20% check-ups remained unfinished. Profound examination and treatment of the patients with pathologies revealed during check-ups that should have followed was complicated by the unwillingness of the patients to attend clinics due to long waiting lists for doctors’ consultations. The amount of forms filling by medicinal personnel increased considerably because of introduction of many accounting forms. At the same time increased amount of documents flow was not supported by computerization of workplaces and modern software provision.
The means of the project were directed to finance additionally health care rendered to women during pregnancy and childbirth. Childbirth certificates were used as an instrument for payment. Children’s outpatient’s clinics became part of this program from 2007. Granting of childbirth certificates to 2.6 mln of women enabled obstetrics institutions to receive consumables and medicines, increase wage of medicinal personnel – by RUR 5000-6000 for doctors, by RUR 3000-4000 for paramedical personnel, by RUR 500600 for junior paramedics. The mechanism of childbirth certificates gave women opportunity to choose medical institutions and stimulated the competition between such kinds of institutions in regional centers and towns with more than 400 thousand of population. Additional funds that antenatal clinics, maternity hospitals, children’s outpatient’s clinics were the factors that affected positively babies death rates. It should be however noted that the trend for this indicator reduction has been registered in Russia since 1994.
National project envisaged financing of high-tech public medical health care. The number of patients for which it was rendered at the expense of the federal budget has increased from 60 thousand in 2005 to thousand in 2007. Whereas in 2006 these means were received only by federal medical institutions, in such health care was rendered by 73 medical institutions of the regions of the Russian Federation. It should be noted that financing of such health care is only formally equal to the right of the patients concerned for free treatment. There is evidence that patients receiving assignments for federal clinics at the expense of the National project have to suffer additional expenditures. Thus Federal Service on Surveillance in Health Care and Social Development revealed instances of ungrounded co-payments while receiving high-tech health care in a number of federal specialized medical centers.
Within the framework of the National project it was envisaged to build 14 centers for high-tech health care. It is obvious that it turned out impossible to put them into commission by the beginning of 2008, as it was primary declared. In 2007 three centers were put into commission (centers for cardiovascular surgery in Penza and Astrakhan and traumatic surgery, orthopedy and endoprosthesis in Cheboksary), construction of others will be finished in 2008.
Results of fulfillment of National project in 2006-2007 testify its doubtless contribution into improvement of resource provision of health care system but its influence on the improvement of the state of health of the population has no reliable evidence so far. National project cannot provide considerable improvement in solution of particular problems of Russian public health care. Bad indicators of population’s health, low insurance of population against the expenses risks in case of illnesses, inequality of such expenses distributions and inequality of availability of health care between different social and regional groups, low efficiency of public health care system – solution of these problems is impossible without large-scale changes in public health care organization and financing. In the National project there are insufficient funds for it, and any large institutional changes that touch all the system of public health care is not envisaged in it.
Accession of the Ukraine to the WTO: lessons for Russia A. Pakhomov On 5 February 2008 at the regular meeting of the General Assembly the pack of the papers on Ukraine’s accession to the World Trade Organization (WTO) was adopted. Membership of the Ukraine in the WTO can have ambiguous consequences for the development of bilateral trade and economic relations and process of Russia’s accession to the WTO.
Thus, starting in 1993 – the same year as Russia – negotiation process, the Ukraine finishes this long marathon. During the last three years the Ukrainian party became significantly more active and conducted bilateral negotiations with more than 50 countries-members of the WTO that expressed their interest, signing with them corresponding Protocols on admission of goods and services to the market as a result. On the whole, these protocols form the conditions for admission of import goods and services to the Ukrainian market under the most favorable conditions. Within the framework of the multilateral talks the Report of the Working party was prepared (its sixth version was approved which is considered to be a good result), in which rights and duties of the Ukraine in the WTO are registered in regard to so-called system issues (concordance of the national legislation and its enforcement with the rules and regulations of the WTO agree ments). In the special addendum the liabilities of the Ukraine concerning budgetary support of the agriculture were formulated.