According to Article 12 of the "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens" dated July 22, 1993, the state healthcare system includes:

ministries and health authorities at all levels;

medical and preventive and research institutions;

pharmaceutical enterprises and organizations;

sanitary and preventive institutions;

institutions of forensic medical examination;

logistics services;

enterprises for the production of medical preparations and medical equipment and other enterprises, institutions and organizations.

The structure of production is determined by the composition of the total needs put forward by a given society. The composition of the needs of the social organism (life benefits necessary for the existence and development of each individual, certain social groups society as a whole) includes the creation of wealth and services. The production of material goods and the production of material services are large areas social production. Healthcare is one of the leading service industries.

From the point of view of the functioning of enterprises (firms) and persons operating outside the sphere of production of material goods, the service sector has no fundamental differences. Generic features of production in this area are determined only by the nature of the created services themselves.

It should be noted that healthcare as a branch of the national economy is very heterogeneous and diverse. As part of modern healthcare, attributed by statisticians to the category of so-called large industries, there is a mass of independent and at the same time extremely closely interacting structural elements, which are defined as sub-sectors of specialization and production. Thus, health care services are as diverse in their manifestation as the health care industry itself is multifaceted and complex (Figure 2).

Figure 2 - The system of functioning of the healthcare industry

In the healthcare system, the primary and closing link belongs to society, since society itself determines and sets the main directions for the work of this system, and the healthcare system in one way or another should work to improve the health of the population. Improving the health status of the population can be carried out both through prevention, (this shows the most efficient work health care system) and through the direct treatment of patients. At the government level, programs are adopted to improve the health status of the population (federal, regional), as well as priority national projects. Resources and personnel are needed to put these programs into action.

Review national models health care shows a fairly large range of possible financing schemes for this industry. It is interesting to note that the principles of insurance medicine in most countries of the world still dominate both completely private and completely public funding.

Currently, all existing health care systems are reduced to three main economic models. These models do not have unambiguous generally accepted names, but descriptions of their main parameters are given by experts, in general, the same way. These are paid medicine based on market principles using private health insurance, state medicine with a budgetary financing system and a healthcare system based on the principles of social insurance and market regulation with a multi-channel financing system.

Consider the effectiveness of each of the models, in terms of the possibility of their application in Russia, in conditions transition economy. For this, we denote character traits, inherent in the transition economy:

1) deficit state budget;

2) reduction in production volumes;

3) high unemployment;

4) low income level of the population;

5) high inflation rates.

In the context of a decline in production and rising unemployment, which entail a deterioration in the quality of life, the need for medical services ah is increasing. Therefore, the functioning of medical institutions needs, first of all, uninterrupted financing. Therefore, in transition period, with its characteristic state budget deficit, one cannot rely on the effectiveness of the state model for organizing the healthcare system.

The low level of incomes of the population and high rates of inflation will significantly limit the effective demand for medical services on the part of individuals. The decline in production and the orientation to survival will not allow firms to carry out voluntary insurance their employees. Therefore, the use of a market model during the transition period will lead to the fact that a significant part of the population will not be able to receive the necessary medical care. This is especially true for such socially unprotected segments of the population as the elderly, the disabled, children, since these are the groups with the lowest incomes, but with the greatest need for medical care. Such negative consequences during the period of economic and political reforms are fraught with a social explosion.

As already noted, during the transition period, people's needs for medical care increase. To ensure the minimum required amount of financing for medical institutions, it is necessary to consolidate all possible sources of raising funds. In the conditions of a state budget deficit and low incomes of the population, only a social insurance model with a multi-channel financing system (from the profits of insurance organizations, deductions from salaries, the state budget) is able to solve this problem.

Formation of healthcare as a branch (sector) of the national economy engaged in the provision of medical services to the population began with the second half of XIX century. Until that time, rendering medical care closed at the level of bilateral relations between the doctor and the patient, and the role of the state was mainly reduced to responding to the negative consequences of such relations from the point of view of criminal liability.

The expansion of industrial production and the increase in the number of workers employed in this production, whose well-being depended to a large extent on their ability to work and its loss due to illness, injury or old age, required the adoption of measures aimed at avoiding undesirable health-related consequences that could put the worker and his family in front of a social catastrophe.

As a result, elements of social solidarity began to appear in the form of health insurance structures, at first scattered, and subsequently consolidated and regulated by legislative acts. Health insurance originated as voluntary public insurance, and the first insurance funds for wage earners were public organizations.

Industrial workers began to create societies of mutual solidarity - funds in case of illness, which were intended only to pay for treatment and compensate for the loss of earnings during the period of illness, but not to make a profit. As the system evolved, some foundations not only paid for any doctor, but also contracted with individual doctors to provide medical care to members of the foundation on a regular basis, and then began to create foundation-owned hospitals and hire doctors.

The management of the health insurance fund was carried out on a public basis by meetings of the members of the fund and its board. Subsequently, the funds of health insurance funds began to be formed on the basis of an agreement from the contributions of both insured employees and their employers. The first examples of this kind are connected with Germany. . Here, health insurance for certain professions was put into practice as early as 1845.

Further understanding of the need to provide sufficient guarantees in matters of social security for all citizens led to the fact that in 1883 the mandatory health insurance for sickness was extended to the entire population of the country. In 1884, a law was passed on health insurance with regard to accidents, and in 1889 - for disability and old age.

According to this legislation, each employee of a certain sector of the national economy, who earns less than the established tariff, had to be insured without fail. Insurance funds were formed at the expense of obligatory insurance payments of employees and their employers.

The system of laws based on compulsory health insurance for these four, the most significant causes of disability for the wage worker, began to be called after the then Bismarck Chancellor. And since similar laws were subsequently adopted in most European countries and in the development of health care they began to see features similar to Germany, the definition of " Bismarck health care system " has become a household word. It meant predominantly compulsory health insurance .

This model is currently active in Germany, Holland, Austria, France, Belgium, Japan and is also known as "regulated insurance". IN this case refers to state and publicly regulated health insurance based on :

• universal coverage;
• the presence of a mandatory minimum of medical services received under insurance;
• participation of the state and entrepreneurs in financing;
• control over the activities of insurance organizations;
• harmonization of tariffs for medical services, general principles their quality control.

Private and others Insurance companies operate within strict limits prescribed by laws and regulations (except for the field of additional insurance), and the share of state subsidies in the field health insurance pretty big.

Budget insurance system , operating in the UK, Canada and other countries of the British Commonwealth of Nations (as well as in Sweden) is a continuation of the policy of state participation in health insurance systems, when the state begins to interfere in insurance relations, and then completely replaces insurance premiums with taxes, which are used to pay work of all representatives of medical services.

Insurance premiums are collected in the form of mandatory taxation, and the corresponding amounts are included in the expenditure part of the budget on a separate line"Health". The distribution of these funds is not carried out by independent insurance organizations and the public administration. At the same time, for citizens-taxpayers, medical care becomes, as it were, free of charge, since there is no need to conclude an individual insurance contract and there are no direct costs for medical care.

In a number of countries that are characterized by a commitment to the idea of ​​free enterprise In the United States, for example, the principles of full state regulation of insurance were rejected and preference was given to promoting a variety of private and local initiatives in this area, as a result of which a system of private insurance was formed . The public sector pays up to half of the costs for the treatment of the poor, the elderly and other vulnerable groups of the population, as well as for public anti-epidemic and preventive needs.

Thus, To date, three health care systems have developed in economically developed countries :

• system of regulated insurance (insurance medicine);
• public health care (state system);
• private health insurance system (market system).

It should be noted that the allocation of these models is based not only on the role of the state, but also on the understanding and definition of the “goods” in the healthcare sector. At the same time, there is still no unambiguous opinion about what is a product in this sphere of life.

Although the main goal of health care is human health, the attempt to consider it as a commodity is very problematic. And above all because it is poorly measurable and difficult to evaluate in terms of money. But most importantly, if such an assessment of a person's health in monetary terms were found, then it would begin to determine the price of human life.

In fact, this price is implicitly present, for example, in calculations related to life safety, in military medicine (when determining priorities in the provision of medical care). However, the explicit definition of the price of human health, and, consequently, human life, is contrary to traditions, culture, and, given its obviously insufficient validity, is seriously and rightly criticized.

In this regard, it is proposed to consider medical services as a commodity, and define the health care system as an organized activity during which these services are produced.

The models of healthcare organization described earlier take into account the specifics of a medical service as a product in different ways. . And this factor is no less important than the role of the state in identifying different types of organization of the health care system.

For example, in the market model, medical services are treated like any other commodity that can be bought or sold in accordance with the classical laws of the market (i.e., with minimal consideration its social characteristics). As already noted, a typical example of a market model is the US healthcare market .

The healthcare sector is represented here developed system private medical institutions and commercial health insurance, where doctors are sellers of medical services, and patients are their buyers. Such a market is closest to the free market and has all its advantages and disadvantages.

Due to intense competition, conditions are being created for quality growth, the search for ever new products and technologies, and the strict rejection of economically inefficient strategies and market participants. This determines the positive aspects of the market model of healthcare . But, on the other hand, insufficient consideration of the specifics of the type of product under consideration (unlimited demand for it, the seller's monopoly, etc.) causes the well-known negative aspects of the market model :

• excessive growth in medical costs;
• impossibility of implementation state control and, consequently, difficulties in setting priorities between health care and other sectors of the economy;
• the possibility of crises of overproduction and stimulation of the supply of unjustified services;
• preconditions for unfair ways of competition;
• excessive influence of fashion and advertising;
• unequal access to health care.

If social specifics considered as the main parameter of medical services, then the fact of buying or selling medical care will mean an indirect purchase of national health. In this case, when organizing the healthcare system, the principle of equal access to medical services will be at the forefront.

The easiest way to ensure this is in a centralized way, by subordinating the health care system to the control of the state. Thus, it is social priorities that prevail in budget system healthcare. A typical example of a government model is the UK healthcare market. . This market is based on the public (national) healthcare system.

The National Health System is called beveridge named after Lord Beveridge, who proclaimed in 1942 the ideas that became the basis of the budget model: the rich pay for the poor, the healthy pay for the sick. With this approach, society tries to pay for the health of the nation through the payment of medical services directed to its maintenance.

In this market, it is much easier to correlate the priorities of the health of the nation with other priorities of the national economy. This model organization of the health care system gravitates towards the market of centralized, planned distribution economies and has characteristic positive and negative features corresponding to such economies.

The disadvantages of the budget model include lack of natural stimulating factors. This leads to a slow increase in the quality of medical care, lack of flexibility organizational structures, to the possibility of long-term implementation of ineffective strategies and the use of old medical technologies.

But there are obvious advantages . First of all, focus on disease prevention. Since, in Eventually If health is paid for, then the doctor is objectively interested in reducing the incidence, reducing the volume of medical services, while in the free market he is objectively interested in the opposite.

Often, equal access to medical care is achieved by severely restricting the patient's freedom of choice of a medical institution (MPI) or a doctor. On present stage in many countries using the state model, they are trying to eliminate such an obvious lack of organization of the health system.

Returning to the Bismarck model, we recall that labor plays the same role in it as capital. Health increases the efficiency of labor, the value of the so-called "human capital". Therefore, it is focused primarily on solving purely economic tasks: ensuring productivity growth and reducing economic losses by reducing labor losses.

However, in addition to insuring the risk of loss of health as such, the state health insurance system provided for the redistribution of income by paying for medical services through insurance funds. This made it possible to achieve a softening of the sharpness social problems associated with the risk of disability for the poor.

Modern health insurance in Germany as a whole has retained the basic principles of the Bismarckian organization of the healthcare system. . Financing is carried out by consolidating funds from various sources: 60% of the funds received by health care facilities are funds of compulsory medical insurance (CHI), of which 25% is insurance for family members of workers; 10% - funds of voluntary medical insurance (VHI), 15% - public funds through taxation, 15% - personal funds of citizens.

In turn, compulsory medical insurance funds are formed from three sources: the state budget, contributions from employees and employers. Contributions are paid by employers and employees in equal shares.

Among the variety of specific forms of organization of the health care system in different countries ah, using the social insurance model, let's dwell on the Japanese health care system .

The health care of Japan is of great interest due to the fact that this country managed to achieve the highest indicators of public health in a relatively short time, and not least, this is due to the conditions and lifestyle.

Japan is the first country in Asia to introduce nationwide health insurance in 1961, and a number of insurance laws that partly offset the cost of medical care were passed much earlier:

• in 1922 - on compulsory insurance of employees;
• in 1938, on national health insurance;
• in 1939 - on the insurance of sailors;
• in 1953 - on the insurance of daily workers.

At present, Japan has developed a public health system, including public hygiene, social security, health insurance, medical care for certain groups of the population at the expense of the state.

Overall, health care spending in Japan is only about 6.6% of GNP. Each medical institution is an independent organization, 80% of hospitals are owned by private practitioners.

Japan's health care is financed mainly by health insurance funds. The vast majority of Japan's population falls under two main health insurance systems: the national health insurance system based on the territorial principle, and the insurance system for employees based on the production principle.

National Health Insurance System covers mainly small proprietors and members of their families, the disabled and other unemployed persons. The insurance premium is collected from them by local governments or the National Health Insurance Association. This contribution depends on the place of residence, income, real estate, family size, 40% of the amount of temporary disability benefits are state subsidies.

Benefits are provided in the form cash payments and preferential medical care. Maximum size benefits can be up to 90% of the cost of treatment (10% is paid by the patients themselves).

Payment for medical care is made on the accounts of medical institutions provided monthly through social insurance. These accounts are preliminarily reviewed by medical consultants to determine the rationality of the services rendered. The calculation is made according to the tariffs for medical services and medicines approved by the Ministry of Health and social security.

There are various programs in the insurance system for employees. Government program health insurance applies to employees of medium and small enterprises (the state itself is the insurer).

In the public health program, the insurer is an insurance company established by the administration and employees of one enterprise or several enterprises of the same industry.

In addition to the health insurance system in Japan, there are public funds , due to which, on the basis of laws, the following is carried out: prevention of tuberculosis, mental and infectious diseases, venereal diseases, leprosy, hereditary diseases, compensation for damage caused to health by environmental pollution.

All of the above is united by the concept of "public hygiene". Public funds also finance activities that are united by the concept of “social security and social welfare”. These measures are carried out on the basis of laws: on the protection of life rights (medical care), on the social security of the crippled and disabled (rehabilitation assistance), on the social security of children, on measures of emergency assistance to the wounded in the war, on medical support for victims of the atomic bombing. In addition, at the expense of public funds, insurance is provided for mother and child.

So, at the heart of each of the considered models of the organization of the healthcare system is a different understanding of what is a product in the field of healthcare . The attitude to the medical service determines the role of the state in the health care system, the formation of prices in the medical services market, and the wages of people employed in this area.

Task text

Activity Write a paper on the topic "National Health Systems". In this topic, it is necessary to reveal the features of the healthcare system and the organization of medical care in various countries. The essay should reflect the story of at least 1 country, but no more than 3 countries. When preparing for an essay, I recommend DO NOT TAKE ready-made papers from the Internet, since during the existence of the course the main types finished works already sent, and their text is familiar to me. In this case, I will give a low rating. If you take, then use the compilation (collection) of information from several works, just use articles on the Internet. For the inconsistency of the design and the absence of the title page, the scores will also decrease, but only slightly. An essay is an independent written work on a topic proposed by a teacher of the relevant discipline or independently chosen by a student on the issues of the course being read. The purpose of writing an essay is to develop the skills of an independent creative approach to understanding and comprehending the problems of scientific knowledge, the possibility of its applied use, as well as the skills of writing one's own thoughts and attitudes to various socio-psychological and social phenomena. The structure of the essay contains the following sections: 1. title page; 2. the content, or brief plan, of the work to be performed; 3. introduction; 4. the main part, including 1-2 paragraphs; 5. conclusion; 6. list of used literature (bibliography). Requirements for the design and content of the essay The essay should be printed in 12 or 14 font, 1.5 intervals (MS Word), with a total volume of 2 to 10 pages. Essay pages should be consecutively numbered. The first page is the title page, on which the page number is not affixed. The text should be justified (it looks like a task text, where the right and left sides are even). Introduction The introduction should include justification of the interest of the chosen topic, its relevance or practical significance. It is important to consider that the stated topic should be adequate to the content disclosed in the essay, in other words, there should be no discrepancy in the title and content of the work. The main part The main part involves a consistent, logical and evidence-based disclosure of the stated topic of the essay with links to the used and available literature, including electronic sources of information. Each of the used and cited literary sources should have an appropriate reference. The culture of writing a written work, and in particular an essay, necessarily includes the presence of conclusions for each section and a general conclusion. Conclusion Usually contains up to 1 page of text, which notes the achieved goals and objectives, conclusions that summarize the author's position on the problem posed and promising areas of possible research on this topic. Literature Several literary sources should be indicated, among which only one textbook can be presented, since the essay requires the ability to work with scientific sources, which include monographs, scientific collections, articles in periodicals. Requirements for writing and evaluating essays can be transformed depending on their form and content, while Special attention given the following criteria: independence of performance of work; creative approach to understanding the proposed topic; the ability to argue the main provisions and conclusions; validity, evidence and originality of the formulation and solution of the problem; clarity and conciseness of presentation of one's own thoughts; the use of literary sources and their competent design; compliance of the work with formal requirements and the genre of independent work.

I. A. Gareeva

MODELS AND NATIONAL HEALTH SYSTEMS: STATUS AND DEVELOPMENT TRENDS

The main challenges facing health care are largely the same around the world. Demographic changes, the spread of chronic diseases, rising health care costs, all of these and other problems may arise before national economies and, accordingly, national health models and systems will be able to cope with them. There are problems of an organizational nature, such as the vagueness (France) or cumbersomeness (Netherlands) of the functioning health care system. Noncommunicable diseases place a significant burden on the health budget, and this burden will increase as the population ages. The experience of most countries shows that deep socio-economic and political transformations expose a number of social problems that require appropriate changes in the industry.

Choice optimal model and the health care system at the present stage is a problem for many national economies. The national model demonstrates the resilience of the healthcare system to ongoing changes, especially in times of crisis. All this determines the relevance of the study of national models and health care systems and their comparative analysis.

At the end of the last century, many problems have accumulated in the organization of healthcare in most countries of the world. These include problems related to deteriorating health status, the quality of care provided, and problems related to the way countries finance their health services and organize medical care. The “deteriorating health status of the population” seems to be quite natural, as the average life expectancy is rising all over the world. On the one hand, old age brings with it already existing diseases, on the other hand, it acquires new diseases. It can be assumed that further progress in medicine will allow saving lives, in the modern concept, of hopelessly ill people and will lead to further growth. medium duration life. However, this will require an even greater volume of medical care and, as a result, an increase in the cost of providing it. Therefore, many governments around the world are constantly reviewing their models and health care systems, as well as the acceptability of the approaches used to organize, finance and provide medical care in order to maintain and restore the health of their citizens.

The measures taken by the countries of the European Region to ensure the optimal functioning of the health sector are very different, since the models and systems of health that operate today were not immediately created in their modern form, they gradually developed and changed over a long time in accordance with national requirements and capabilities. Traditionally, there are three models of health care: predominantly public, predominantly

© I. A. Gareeva, 2010

insurance and mostly private. In order to get a clearer idea of ​​the advantages and disadvantages of a particular model and various systems health care, it is necessary to review and analyze the health care systems operating in different countries of the world, compare data in terms of efficiency and compliance with the principles of social justice in the provision of medical care.

The main directions of reforming the national health care system are in most countries the course towards decentralization and delegation of some state functions regional and municipal authorities and the private sector. The organization of the functioning of the planned market played an important role in health care reform in Great Britain, Spain, Italy, Finland, Sweden, as well as in various countries of Central and of Eastern Europe. Thus, according to the European Observatory on Systems and Policies, as a result of reforming health care systems in these countries, there is a low mortality rate for adult women, adult men, and children in the first five years of life.

In different countries of the world, the amount of spending on health care varies greatly and in order to characterize the level of development of the country's health care system, it is correlated with gross domestic product (GDP). The guaranteed volume of services directly depends on the level of health care spending. Thus, the dynamics of health care expenditures from GDP in France is 9.5%, in Germany -10.6%, Great Britain -7.3%, Italy -8.1%, Portugal - 8.2%, Spain - 7.7%. %, USA - 13%, Japan - 7.8%. Thus, one of the tasks of any government is to ensure, in one way or another, a certain share of GDP spent on health care. However, a direct interdependence of these indicators has not been identified and is unlikely to exist (Table 1).

To,blitz, 1. GDP and life expectancy

Country GDP per capita, US$ Life expectancy at birth, years Per capita health care expenditure, US$

Russia 6744 67 743

Austria 22135 77 2546

Belgium 22217 77 2602

UK 19533 77 2120

Germany 21336 76 3015

Denmark 23147 75 2078

Italy 20254 78 2736

Canada 22743 78 2437

Netherlands 21041 78 2621

USA 27840 76 3154

France 20396 78 4467

Switzerland 24943 78 2863

Sweden 19942 79 2308

Japan 23987 80 3647

Thus, the impact of the financial content of the health care system does not always bring an improvement in the values ​​of social well-being indicators, such as an increase in life expectancy, a decrease in morbidity, etc.

In the UK, Italy, Sweden and Canada, government budgets are important sources of funds for health services and rarely account for less than 60% of the total spending in this sector, sometimes as high as 90%. Almost 90% of medical care costs are covered from the UK state budget, in Sweden - 91%, in Italy - 87%, in Canada -76%.

To determine whether countries are spending enough on health care, the World Health Organization (WHO) and the Commission on Macroeconomics and Health have attempted to determine this level. Despite a number of assumptions, in both cases the results were similar: the necessary minimum level of funding for the system, providing the population with the necessary medical services, is 80 US dollars per year per capita. The Commission on Macroeconomics and Health used parity calculations purchasing power. WHO took a slightly different approach by analyzing the relationship between health care spending and population health using the DALY indicator. With different health care models and systems, what is common to all is high proportion GDP spending on health care (6-14%) and growth in spending allocated to health care. Thus, the level of costs for maintaining health is: in the UK - 1000 US dollars per capita per year, in Germany - 2000, in the USA - 3000.

One of the characteristic sources of health financing is the state budget. The public health system is financed from general tax revenues and guarantees medical care to all categories of the population. At the same time, the main part of medical institutions belongs to the state, management is carried out by central and local authorities. This principle underlies the creation financial systems health care systems where public health systems exist. Such an organization is envisaged in the health care systems of Great Britain, Italy, Ireland, Norway, Sweden, Denmark, Spain, Canada and Portugal. The health care systems of France, Germany, the Netherlands, Belgium, Austria and Japan are based on health insurance with varying degrees of state participation in the financing and management of the health insurance system. Despite a certain orientation in health care financing, it cannot be argued that there is a “pure” model of the health care system. In the countries of Western Europe public health either less severely or not at all restricted the opportunities for the parallel existence of private entrepreneurship in health care. The public health care system is financed from general tax revenues to the state budget and covers all categories of the population. All or the main part of medical institutions belongs to the state. State subsidies (budget receipts) are carried out in the form of state transfers. With their help, the state achieves the optimization of individual consumption, while in public procurement, resources are redistributed from private consumption of goods and services to public consumption.

The most indicative country with a system of budgetary financing is Great Britain. Along with the national health service, there is also a private sector in the UK health care system, which is insignificant in general practice, but has a lot of weight at the level of secondary care. But the presence of a single large source of funding creates

a number of serious problems. Thus, the problem of insufficient allocations for health care is much more acute in the UK than in other countries. The resource deficit affects the presence of long queues for hospitalization. The system of "socialized medicine", as it is also called, guarantees, at first glance, equal access to all citizens to the necessary medical care. However, the state has to intervene in the process of consuming medical services by introducing a rationing mechanism. With universal access to health services, some groups of the population have a preferential position in relation to others. Thus, residents of economically prosperous regions have an advantage, since the majority of doctors also prefer to practice in these regions. Undoubtedly, persons high level income earners are in a better position to avoid waiting in line by taking advantage of private insurance or out-of-pocket health care. At the same time, the state nature of the UK health care system does not exclude the manifestation of social inequality in the availability of medical care for certain groups of the population.

The Swedish health care system is a publicly funded national system. More than 90% of all its expenses are covered by public funding sources. Individual payments of citizens account for about 3% of all health care costs. The Swedish health care system includes three levels: national, regional and municipal. The majority of health care spending is covered by taxes levied at the regional level, accounting for 75% of all health care spending. In Sweden, most health care providers are state-owned and owned by regional authorities, but have autonomy in decision-making on operational management.

Spain's national healthcare system is heavily licensed. All issues related to health care are transferred to the autonomous territories, and the entire health management service is formed from the central administration and regional health authorities at the level of autonomous territories. The Spanish health care system is financed 80% from general taxes and 20% from social security funds. Since funding is currently decentralized, about half of the budget is spent at the regional level. More than a third of all spending falls on the private sector. For the high-income group (6%), there is a private sector alongside public health.

The predominantly insurance model of healthcare is typical for France, the Netherlands, Germany, Belgium, Austria, as well as Japan and Canada. In countries where the national health care system is built on the principle of insurance medicine, public authorities take part in the management of health care, while funding is provided from earmarked contributions employers, personal funds of employees and, as a rule, budget allocations from general or earmarked revenues.

Health insurance is, in its content, a mixed source of funding for the health care system, as contributions come from employees, employers and the government. Health insurance covers individuals or groups through a third party operating in the private sector. The amount of insurance premiums is established taking into account the calculation of the cost of treating diseases and using medical services. The share of contributions from employers and workers

The dwindling workforce in countries with such a health system is between 4% and 20% of total health spending. The share of public sector participation in health financing in these countries also differs and, for example, in Sweden, Finland, Canada and Iceland it is more than half. Compulsory (basic) health insurance covers almost the entire population of countries with such a system of healthcare organization. Private (voluntary) insurance acts as a complementary link. The insurance systems in these countries are managed government bodies power, but unlike government systems are financed through earmarked contributions from entrepreneurs and employees.

Canada's health insurance-based health care system is an intermediate form between public (public) health care and private medical business and is one of the best, according to many experts. At the same time, if we talk about the predominant nature of the Canadian health care system, it should be considered as a budget-insurance one, since most of the financial resources come from the state budget, the rest are social insurance funds.

federal law on health care guarantees Canadians the right to receive any type of health care, regardless of the level and funding of health care programs. The positive features of the Canadian version of the healthcare system are, first of all, universality, comprehensiveness and accessibility.

Not in Italy unified system medical insurance. Almost 92% of the population is insured in various insurance companies, each of which provides medical care to a particular category of the population. The largest insurance company is the National Insurance Institute, which covers almost half of the country's population. The state provides financial assistance to insurance medicine only when it detects a shortage of funds.

In Austria, centralized administration, the development of health care strategies and tactics, as well as the drafting of health legislation, lies with the federal Ministry of Health, Sports and Consumer Protection. Medical provision is achieved mainly by general social insurance of citizens. Insurance medicine covers about 60% of the population. Everything else falls on private medicine. Insurance premiums are: 4.5% of the salary for officials, 4.8% for office workers, 7.2% for workers. Pensioners allocate 2.5% of their pensions for health insurance.

The German healthcare system is virtually out of state regulation and intervention. The German federal government plays a minor role in health care, as the main power and management functions (for example, hospital care) are transferred to the federal states, but the legislation on outpatient care still belongs to the federal government. The virtual absence of rigid centralization makes the German health care system very diverse and leads to an increase in the role of various private, semi-public and government organizations. Determination of resources intended for health care is the responsibility of local authorities. Within the limits of the health insurance system, a general payment is made for medical and dental care, medicines and sanitary items, hospital care and, in certain cases, home care. In addition, financial and medical assistance is provided during pregnancy and childbirth.

Health care costs are covered from various sources: from taxes - 12%, insurance premiums from employees - 27%, insurance premiums from employers, direct payments by employers - 15%, and private insurance premiums - 7%. The remaining health care costs are covered by the patients themselves.

Approximately 90% of the population is protected by the social insurance system, which is carried out mainly through the contributions of the insured and employers (sick leave, pension and unemployment insurance). Accident insurance is financed exclusively from employer contributions. Separate types insurance companies receive government subsidies. The amount of contributions is determined by the tariff of contributions and the basis for their calculation.

The Swiss healthcare system is financed by federal, cantonal and municipal governments (25%), public insurance funds (43%) and private insurance funds (32%). Social insurance contributions are usually independent of income, strictly individual and differentiated according to age and gender. Tariffs for medical services are determined by negotiations between professional medical organizations and representatives of foundations at the cantonal level.

Health care in Switzerland is based on the financial provision of mutual funds. Monthly contributions of employees to mutual benefit funds amount to about 5% of earnings. The state exerts a regulatory influence on insurance medicine and provides additional financing to insurance companies. In the country, about 90% of the population is covered by the social insurance system, which is provided by insurance funds (over 190). Approximately 30% of the population is additionally insured by private insurance companies. According to the law on social insurance, which determines the structure of health insurance, it is not mandatory at the federal level, since these matters are under the jurisdiction of the cantons. As a result, there are significant differences between the cantons. For example, in 5 of the 26 cantons, social insurance is compulsory for the entire population, while in others, compulsory insurance is provided only for certain specific groups (the elderly, low-income groups, etc.). Some cantons generally offer social insurance only on a voluntary basis.

Given the financing of the Swiss healthcare system, we can say that to a large extent this system is a budget-insurance system, and not an insurance one in its purest form.

Japanese health care is generally based on compulsory health insurance, which provides the entire population of the country with medical care with free choice. medical institution and a doctor.

Compulsory medical insurance in Japan is of a state nature, providing social guarantees to citizens from the state in the field of health care. At the same time, employers are the insurers of the population working at large enterprises. For all other categories of the population, including freelancers, the state itself is the insurer.

On average, about 8% of the payroll fund is spent on health care at enterprises. Health insurance does not exempt a worker from participating in paying for medical services. When applying for medical care, a working Japanese has to pay 10% of the total cost of his treatment from his own income.

France has a healthcare system mixed type, connecting

various in itself organizational principles. The system is funded by health insurance premiums, but is tightly controlled government controlled. It has public and private health insurance funds that jointly finance the same curative, preventive, and rehabilitative services provided by the same manufacturers and providers to the same population groups.

A publicly funded health care system provides free choice of doctor and unrestricted access to medical services, and doctors the freedom to professional activity. The mixed nature of the French health care system reflects a balance between social justice, freedom and economic efficiency, but creates structural difficulties that make it necessary to reform the health care system.

In France, health care spending is outpacing economic growth as life expectancy and the proportion of older people increase in the country. Yes, ten recent years health care spending has risen from 82 billion euros to 157 billion euros, averaging between 1,453 and 2,580 euros per person. The share of health spending in GDP ranges from 9.5% to 10.4%.

The French healthcare system, recognized by WHO as one of the most successful in terms of treatment, is in crisis. The high qualification of medical specialists is no longer fitting into the vague structure of health care, in which it is very difficult to understand who does what and who pays for what. The crisis is primarily affected by stationary medical institutions.

To overcome the crisis in health care, the state provides financial support to the regions through public investment, innovative approaches and organization of billing activities. Tariffic activity includes systems of general subsidies and fixed and predetermined tariffication. However, organizationally and functionally, these systems are poorly comparable, difficult to combine, and thus hinder the necessary interaction between regional elements of health care and further aggravate the current situation in the industry.

This situation in the French healthcare system has necessitated reforming the way the industry is financed in order to improve the efficiency of public health care and ensure fairness in the provision of hospital care. The modern health care model as a result of the reform is focused on determining the real volumes of medical care based on needs, ensuring fairness in the availability of medical care.

There are three levels of administration in the Dutch health care system: state, provincial and municipal. The insurance system in the Netherlands is carried out in accordance with two schemes. Compulsory insurance applies to employees with income below a certain level, older pensioners and persons with social benefits. Compulsory insurance currently covers approximately 60% of the population. Accordingly, about 40% of the population are clients of private health insurance. Despite the cumbersome organization, the Dutch healthcare system is in constant reform, which allows you to achieve optimal results in functioning. Thus, plans are currently being considered to create a unified system

health insurance covering the entire population, financed 85% by tax revenues and 15% privately.

In the United States, a decentralized private insurance system has now been preserved, that is, more than 80% of Americans buy health insurance policies from various private insurance companies, spending more than 10% of their family's net income on this. The American insurance system considers it incorrect when healthy people support persons with a high risk of disease or patients with their insurance premiums. Therefore, health care for low-income people and the elderly is provided through the public programs of Medicaid and Medicare.

The state in the US national health system plays the following role: organizes mass surveys of the health of the population, develops policies and standards in the field of health care, deals with issues of legislation in health care, provides support scientific research in the field of medicine and health, finances the provision of medical care under the Medicare and Medicaid programs for the elderly and people with low level revenue, provides resource support and technical assistance to state and local health care. For the general population of the country, with the exception of groups to be served under the Medicare and Medicaid programs, medical care is provided through private insurance companies and various forms group insurance. The amount of assistance depends on the amount of the contribution. The proportion of Americans left without health insurance is youth and small business workers.

Conducted analysis modern models and health care systems indicates that there are no "pure" models and health care systems, just as there are no ideal ones. Any model or system of health care, to a greater or lesser extent, gives rise to organizational, structural and financial difficulties, and as a result - social inequalities in the field of public health. An increase in health spending will not improve the health of the population and will not completely eliminate existing problems, but it may become a risk to the sustainable development of the system itself, especially in an economic crisis.

Thus, increased funding will not solve the challenges facing any national health system. A unified comprehensive concept of health care is needed, regardless of the model and health care system, which would allow to identify the existing needs of the population and develop the most effective ways their satisfaction. This requires methods and mechanisms that guide financial resources for specific purposes of the healthcare system, as well as timely identification of the most unfavorable places in the field of preserving the health of the population.

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Reduction public funding health care has affected the reduction of free medical services, the availability of free medical care to the population has decreased.

Contrary to fairly common ideas, not only the general level of resource provision, but also structural characteristics Russian healthcare extremely unsatisfactory. In the reforms in health care, too much importance was given to the introduction of a new method of financing. This is probably due to the fact that the main reason for the shortcomings was considered to be the lack of funds. As a result, the quality medical care health, efficiency and value for money have received very little attention.

Thus, it is necessary to point out the irrationally large share of inpatient care in the total volume of medical and preventive care (in Russia 65–70%, in Western Europe up to 35–50%), the low proportion of doctors providing primary care (in Russia 20–25%, in Western Europe 50-60%), excessive specialization and insufficient qualification of the staff conducting outpatient appointments.

The role of much cheaper and more efficient outpatient care aimed at prevention, early detection and timely treatment of diseases. The existing organizational model cannot fully ensure that patients receive medical care in their usual social environment.

New organizational forms of medical care, which would significantly increase the efficiency of the entire system of its provision, are not yet being properly disseminated. In the healthcare sector in Russia, relatively recently, attempts have been made to comprehensively comprehend the processes of restructuring, while there are no final and accurate ideas about its reorganization, directions for increasing efficiency, and the distribution of roles between the state, patients, doctors, and medical institutions.

Today it can be noted that the following tasks have not been solved during the reform: the timely formation of a horizontal in the interaction of healthcare institutions as a result of breaking the vertical; creation of a competitive environment, both for insurance organizations and for medical institutions, regardless of ownership, based on the introduction of market mechanisms for regulating and functioning of the industry; improving the quality of medical care on the principles of standardization and optimization of diagnostic and treatment methods; ensuring the guarantees and rights of patients and health workers; determination of the amount of resources that allow medical institutions to provide standards of medical care to the network that health authorities can maintain; prevention of misappropriation of funds; overcoming costly drug provision.

Reforms, by making the health care system more rational, should have freed up funds to meet the needs of the population. However, health indicators are low and reforms are progressing well. Perhaps, where the interests of medical institutions can be managed, the cost-effectiveness of medical care increases. However, it is premature to draw general positive conclusions. To a large extent, much is due to the incomplete implementation of the law on health insurance and the fact that medical institutions perform only a part of the functions assigned to them. Consumer choice has not changed, although the reforms intended to expand it. Only those who pay have a choice, and the quality of medical care has improved only in paid institutions.

The evolution of the healthcare system, affecting all elements of the system, strengthens the role of the sphere management. The industry found itself in a situation where administrative and managerial methods that hindered the process of its development could not be canceled, and at the same time, it as a whole and its individual medical and preventive structures did not receive clear, theoretically developed new principles and forms of management.

The crisis in domestic healthcare as a whole is caused both by the general economic situation of the country's economy and by the imperfection of principles and adequate management methods in the emerging market of medical services. At the same time, if at the initial stage of the reforms the task was to ensure the uninterrupted provision of health care and medical care, today the main measures should be related to improving the efficiency of service delivery, curbing the growth of costs, encouraging competition, diversifying sources of financing, as well as a new combination of efforts of private and public sectors in the provision of health services.

An example of enhancing the participation of the non-state sector of the economy in the provision of health services is the implementation of the Health project in the part that concerns the provision of high-tech medical care. At the beginning of the project, the business community was not interested in this kind of participation due to the high resource intensity of the first stage of the project, which requires significant one-time capital costs, focused not on economic, but on social and medical efficiency. However, today there are elements of interest in direct participation in the project. This will provide an increase financial stability medical organizations.

It is necessary to note the important role of the medical industry in supporting the development of primary health care, disease prevention, medical examination of the population and providing for the provision of healthcare facilities with diagnostic equipment. It should be noted that the fulfillment of this role is determined by how the issue of applying the national regime is resolved, which provides for the admission of foreign participants to the tender for state deliveries on an equal basis with Russian ones, if similar conditions are established for Russian goods when holding tenders abroad. Such rules are still being violated, and goods from countries that prohibit or significantly restrict the access of Russian goods to their own state supplies are allowed to be supplied to the state.

Thus, the domestic healthcare system needs significant changes that will allow it to get out of the crisis and improve the quality of medical care. Undoubtedly, to implement changes in the health financing system, it is necessary to:

further modernization of compulsory medical insurance, based primarily on a clearer definition of the composition of medical care that the state can provide to the population free of charge within the framework of the compulsory medical insurance system;

increasing the availability of medical services in terms of citizens receiving an alternative choice of conditions for receiving medical care, which will contribute to obtaining a higher quality of medical services for people who are ready to spend their money on it own funds;

change legal status medical institution to ensure a consistent transition to targeted budget financing federal organizations health care and guarantee them a certain independence in making economic decisions;

transformation of polyclinics into consultative and diagnostic centers and systems of independent and competing medical practices operating on the basis of contractual relations with the financing party, hospitals and other medical organizations;

improving the policy of public authorities horizontally and vertically and ensuring its complexity and consistency; creation of a system of integrated health care planning, which implies the evolutionary nature of the restructuring of the health care system and the testing of all actions in pilot areas;

creation of medical innovation centers at the federal, interregional and regional levels as an addition to the construction and equipping of health care with imported equipment for new medical institutions;

creation of a unified telemedicine network of high-tech medical care centers, which can be implemented as an integral part common task global medical informatization of the country;

using the experience of management in the health care systems of developed countries that function with a sufficient degree of stability, as well as the implementation of experimental management models in the country with an analysis of the relevant results; construction of simulation and optimization models in management using new information technologies.

Nevertheless, it is obvious that such measures are of a structural and functional nature, they give a certain direction for maneuver in a specific period of time. At the same time, it remains unclear what kind of model will be the most appropriate for the development of the country and what are the long-term prospects for the development of the healthcare system, which can be considered as systemic changes in the Russian healthcare model, allowing integration into the global healthcare system.

Conclusion

The viability of health care systems of a high degree of will, in particular liberal ones, which in their dynamism of development are based on a constantly transforming basis economic patterns, as can be seen, is hardly amenable to the strategy of classical planning due to the constant mobility of internal and external contradictions, which are the basis of the life and development of such systems.