RUSSIAN PEOPLES FRIENDSHIP UNIVERSITY

DEPARTMENT OF PUBLIC HEALTH, HEALTHCARE AND HYGIENE.

ABSTRACT ON THE TOPIC:

"Organization of medical and preventive care for the rural population."

Lecturer Kicha D.I.

completed by a 5th year student

Shadrunova Ksenia

ML 508 group

MOSCOW 2014

Medical care for the rural population is based on the basic principles of healthcare organization. However, there are factors that influence the organizational forms and methods of work of rural medical institutions:

The nature of the settlement of rural residents, the average number of residents in one settlement

Service radius, distance and condition of roads, transport

The nature of agricultural work and living conditions

National characteristics and customs of some nationalities

Medical staff turnover

Economy and cultural level

Geographic and climatic conditions

In this regard, a number of features of the organization of medical care in the countryside are distinguished, the main of which are:

· Stages

· Continuity

The presence of special medical institutions in the countryside

Application of special organizational forms and working methods

Stages of providing medical care to the rural population and types of rural health care institutions

1st stage - rural medical area.

Includes a complex of medical institutions:

A) a rural district hospital (SUB, provides both outpatient and inpatient care) or a rural medical outpatient clinic (SVA, provides only outpatient care)

B) feldsher-obstetric station (FAP)

C) health centers (if there is an industrial enterprise in the served area).

The main function of the stage: provision of first aid, first qualified medical aid with possible elements of specialized medical aid.

Feldsher-obstetric station (FAP)- the nearest medical institution to the place of residence, which provides medical assistance to rural residents. The presence of FAP is one of the features of rural health care, due to the need to bring medical care closer to the population in the conditions of a large service radius of the district hospital and a low density of rural residents. The recommended standard for the number of residents for the organization of FAP is 700 and more, with a distance to the nearest medical institution of at least 5 km.

FAP functions:

· Provision of first aid medical care and timely fulfillment of doctor's prescriptions;

· Carrying out preventive work and anti-epidemic work;

Organization of patronage for pregnant women, children,

· Carrying out measures to reduce infant and maternal mortality;

· Hygienic training and education of the population.

District hospital- This is the main institution on the SVU, consists of a hospital and an outpatient clinic. Depending on the number of beds, there can be category I - for 75-100 beds, II - 50-75 beds, III - 35-50 beds, IV - 25-35 beds. The local hospital provides all types of qualified medical and preventive care. Medical assistance to the population during field work is of great importance. Considerable work is being done to protect the health of women and children, to introduce modern methods of prevention, diagnosis and treatment.

All types of medical and preventive care for pregnant women, mothers and children are provided local hospital doctor... If there are several doctors, then one of them is responsible for the health of children and women in this area.

Organization of SMS work:

Provision of medical and preventive care to the population

Introduction into practice of modern methods of prevention, diagnosis and treatment of patients

Development and improvement of organizational forms and methods of medical care for the population, improving the quality and efficiency of medical and preventive care

Organization and implementation of a set of preventive measures among the population of the site

· Carrying out treatment and prophylactic measures to protect the health of mothers and children

Study of the causes of general morbidity and morbidity with temporary disability and the development of measures to reduce it

Organization and implementation of prophylactic medical examination of the population, especially children, adolescents

Implementation of anti-epidemic measures (vaccinations, identification of infectious patients, dynamic monitoring of persons who were in contact with them, etc.)

· Implementation of the current sanitary supervision over the condition of production and communal facilities, water supply sources, children's institutions, public catering establishments;

· Carrying out treatment and prophylactic measures to combat tuberculosis, skin and venereal diseases, malignant neoplasms

· Organization and implementation of measures for sanitary and hygienic education of the population, promotion of a healthy lifestyle, including rational nutrition, increased physical activity; combating alcohol consumption, smoking and other bad habits

Wide involvement of the public in the development and implementation of measures to protect public health

2nd stage - regional health care institutions.

The leading place is central district hospital (CRH). The CRH carries out the main types of specialized medical care and at the same time performs the functions of a health management body in the territory of the municipal district.

The capacity of the CRH, the profile of specialized departments within it depend on the population size, structure and level of morbidity, other medical and organizational factors and are determined by the administrations of municipalities. As a rule, CRHs have a capacity of 100 to 400 beds, and the number of specialized departments in it is at least five: therapeutic, surgical with traumatology, pediatric, infectious and obstetric-gynecological (if there is no maternity hospital in the area).

The chief physician of the central district hospital is the head of health care of the municipal district, appointed and dismissed by the administration of the municipal district.

Methodological, organizational and advisory assistance to doctors of complex therapeutic areas, paramedics of FAPs is carried out by specialists from central regional hospitals. Each of them, according to the approved schedule, travels to the integrated therapeutic area for medical examinations, analysis of dispensary work, and selection of patients for hospitalization.

In order to bring specialized medical care closer to the rural population, interdistrict medical centers The functions of such centers are performed by large CRHs (with a capacity of 500-700 beds), capable of providing the population of this municipal district with the missing types of specialized inpatient and outpatient medical care.

The structure of the CRH has polyclinic, which provides primary health care to the rural population in the direction of paramedics of FAPs, doctors of outpatient clinics, centers of general medical (family) practice.

The provision of out-of-hospital and inpatient medical and preventive care to children in the municipal district is entrusted to children's consultations(polyclinics) and children's departments of central regional hospitals. Preventive and curative work of children's polyclinics and children's departments of regional hospitals is carried out on the same principles as in city children's polyclinics.

The provision of obstetric and gynecological care to women in the municipal area is entrusted to antenatal clinics, maternity and gynecological departments of the central district hospitals.

3rd stage - regional healthcare institutions.

Regional Hospital Is a large multidisciplinary medical and prophylactic institution that fully provides highly qualified highly specialized assistance to residents of the region. This is the center for organizational and methodological management of medical institutions located in the region, a base for specialization and advanced training of doctors and nurses.

Regional hospital structure:

1. Hospital.

2. Consultative clinic.

3. Other units (kitchen, pharmacy, morgue).

4. Organizational and methodological department with a department of medical statistics.

5. Department of emergency and planned consulting assistance, etc. (see question 104).

The bed capacity of the regional hospital for adults is 1000-1100 beds, for children - 400 beds.

Consultative polyclinic provides the population with highly qualified, highly specialized medical care, provides field consultations, by phone - correspondence consultations, analyzes the activities of medical and prophylactic institutions, the discrepancy between the diagnoses of the sending institutions and the polyclinic, diagnoses of the polyclinic and the hospital, error analysis. Does not have the right to issue sick leave.

Children and women in the region receive all kinds of qualified specialized medical care in the consultative polyclinic. Inpatient care for women is provided in regional maternity hospitals, regional dispensaries and other medical institutions in the region.

Outpatient qualified specialized dental care is provided to patients in regional dental clinics, inpatient - in dental departments of regional hospitals.

Medical assistance to the rural population is provided on a general basis, but the implementation of therapeutic and preventive measures in the optimal volume and at a sufficient level is complicated by a number of circumstances that must be taken into account when organizing it, namely: socio-economic, medico-demographic, medico-social, natural conditions , stages, infrastructure development, a significant part of first aid, the creation of mobile forms of medical and preventive care.

The organization of medical care for the rural population is based on the principles of staging. There are four stages of providing assistance:

Stage I - the rural medical district provides primary health care.

Stage II - regional medical institutions provide mainly secondary (specialized) care.

Stage III - regional hospitals and dispensaries provide highly specialized care.

Stage IV - interregional and state specialized centers.

At each stage, the activities of all medical institutions are interconnected.

I. Rural medical area - organized to provide medical care to residents of settlements remote from the regional center. It includes a district hospital or outpatient clinic and feldsher-obstetric points.

Tasks of the rural medical area:

providing medical and preventive care to the population;
anti-epidemic measures;
taking measures to protect the health of mothers and children;
implementation of in-line sanitary supervision over the territory, objects of economic activity, educational and educational institutions;
study of the state of health of the population;
carrying out measures for the hygienic education of the population.

A rural medical area is created to provide primary health care on a local basis for residents of settlements remote from the regional center. The average population on the site is 3800 inhabitants and with an average service radius of 7.2 km. When organizing the site, the population size, the distance between settlements, the features of settlement, the area of the district are taken into account.

A rural district hospital is located in a so-called village settlement with a significant population and has an average capacity of 15.7 beds.

The structure of the SC includes: an outpatient clinic, a clinical laboratory, a hospital, an X-ray room, a physiotherapy room.

The functions of the SMS are: timely detection of diseases, the provision of outpatient and inpatient care, preventive measures, dispensary observation and examination of disability.

Inpatient care, which is provided in the district hospital, is mainly of a therapeutic profile, although sometimes emergency surgical care is provided, children and infectious patients are hospitalized.

The district hospital includes a rural medical outpatient clinic. It can also exist on its own. The staffing table defines the presence of four specialists who provide outpatient care: a therapist (family doctor), a pediatrician, an obstetrician-gynecologist (in settlements with a population of over 1000 people) and a dentist.

The rural outpatient clinic carries out timely detection and treatment of diseases in the outpatient clinic and at home: timely hospitalization, referral for consultations to specialists; conducts the selection of persons for dispensary observation; conducts an examination of temporary disability, sends to MSEC; conducts dynamic monitoring of the health of pregnant women and children, conducts health-improving and anti-epidemic measures.

A significant number of villages with a small number and their significant remoteness from healthcare institutions contribute to the development of mobile forms of medical care (mobile medical outpatient clinics, dental offices, diagnostic complexes for fluorography).

Together with the rural outpatient clinic, outpatient and polyclinic assistance to the population at the pre-medical stage is provided by the feldsher-obstetric center (FAP).

The main tasks of the FAP are: the provision of medical and preventive care (first aid, patronage of pregnant women and children, participation in clinical examination) and the conduct of sanitary and educational activities (preventive vaccinations, identification of infectious patients, participation in the flow sanitary supervision).

The following institutions belong to the II stage of rendering medical care to the rural population: the central district hospital (CRH), the district hospital, the district SES, and the central district pharmacy.

The main institution for the provision of secondary specialized care is the RCH. The main functions of which are the provision of outpatient and inpatient specialized medical and preventive care, as well as emergency and emergency care, consultation of patients.

The CRH includes specialized departments: therapeutic, surgical, infectious, neurological, children's, obstetric and gynecological. On the basis of the CRH, other specialized departments (cardiology, gastroenterology, traumatology, otolaryngology, ophthalmology) can also be created, which work as interdistrict ones. They carry out consultative reception of patients from assigned areas and their hospitalization, as well as develop measures to improve the quality of specialized care and improve the qualifications of medical personnel.

CRH structure:

polyclinic;
hospital;
an ambulance and emergency department;
pathological and anatomical department;
information and analytical department.

Tertiary highly specialized highly qualified medical care for rural residents is provided by stage III institutions, which include regional hospitals, dispensaries, regional SES, blood transfusion stations, and forensic examination bureaus.

The tasks of the regional hospital are: consultative polyclinic care, highly specialized inpatient care, organizational and methodological work (assessment of the health status of the region's population, analysis of the activities of all health care facilities in the region and individual services, drawing up an action plan to improve the quality of medical care, professional development of medical workers).

CRH structure:

consultative clinic;
hospital;
medical support and diagnostic units;
center for medical statistics;
departments of emergency and planned advisory assistance;
administrative part;
pension.

Highly specialized medical care for the rural population is also provided by interregional medical institutions and centers that are part of research institutes, universities, regional hospitals or existing independently (IV stage of medical support for the rural population).

The main feature of providing medical care to the villagers is its stages. Conventionally, there are three stages in the organization of medical care for the rural population (Fig. 17.1).

First step- healthcare institutions of a rural settlement, which are part of integrated therapeutic site. At this stage, rural residents receive first aid, as well as the main types of medical care: therapeutic, pediatric, surgical, obstetric, gynecological, and dental.

The first medical institution that a villager usually turns to is feldsher-obstetric station (FAP). It functions as a structural subdivision of a local or central district hospital. It is advisable to organize FAPs in settlements with a population of 700 or more with a distance to the nearest medical institution over 2 km, and if the distance exceeds 7 km, then in settlements with a population of up to 700 people.

The FAP is responsible for solving a large complex of medical and sanitary tasks:

Carrying out activities aimed at preventing and reducing morbidity, injuries and poisoning among the rural population;

Reducing mortality, especially infant, maternal, working age;

Provision of pre-medical care to the population;

Participation in the current sanitary supervision of preschool and school educational institutions, utilities, food, industrial and other facilities, water supply and cleaning of populated areas;

Carrying out door-to-door rounds according to epidemiological indications in order to identify infectious patients, persons in contact with them and those suspected of infectious diseases;

Improving the sanitary and hygienic culture of the population. Thus, FAP is a health care institution

more of a prophylactic focus. At FAP

Rice. 17.1. Stages of providing medical care to the rural population

entrust the functions of a pharmacy for the sale of finished dosage forms and other pharmaceutical goods to the population.

The FAP is headed by head of FAP, the main tasks of which are:

Organization of treatment-and-prophylactic and sanitary-epidemiological work;

Outpatient reception and treatment of patients at home;

Provision of emergency and emergency medical care in case of acute diseases and accidents (injuries, bleeding, poisoning, etc.) with the subsequent referral of the patient to the nearest medical and preventive institution;

Preparing patients for admission to a physician at a FAP, conducting clinical examinations of the population and preventive vaccinations;

Carrying out anti-epidemic measures, in particular household rounds for epidemiological indications in order to identify infectious patients, contact persons and persons suspected of infectious diseases;

Provision of medical care to children in preschool and school educational institutions located in the territory of FAP activities and do not have appropriate secondary medical workers in their states;

Conducting sanitary and educational work among the population. A person who has received secondary medical education in the specialty "General Medicine" and has a certificate in the specialty "General Medicine" is appointed to the position of the head of the FAP.

In addition to the head of the FAP, there is a midwife and a visiting nurse.

FAP midwife is responsible for the provision and level of provision of pre-medical care to pregnant and gynecological patients, as well as for health education among the population on the protection of mothers and children.

The midwife is directly subordinate to the head of the FAP, and the methodological management of her work is carried out by the obstetrician-gynecologist of the medical-prophylactic institution, who is responsible for providing obstetric and gynecological care to the population in the territory of the FAP.

Patronage nurse carries out preventive measures to improve the health of the child population. To this end, she solves the following tasks:

Carries out patronage of healthy children under the age of 1 year, including newborns at home, monitors the rational feeding of the child;

Carries out measures for the prevention of rickets and malnutrition;

Carries out preventive vaccinations and diagnostic tests;

Carries out preventive work in preschool and school educational institutions (located in the territory of FAP and does not have the corresponding nurses in their states);

Prepares sick children for admission to FAP by a pediatrician;

Conducts household visits according to epidemiological indications in order to identify infectious patients, persons in contact with them and suspected of infectious diseases, etc.

In the absence of a patronage nurse in the staffing table, the midwife, in addition to her duties, monitors the health and development of children 1 year of life. In the absence of a midwife and a visiting nurse on the staff of the FAP, their duties are performed by the head.

Despite the important role of the FAP, the leading medical institution at the first stage of providing medical care to the villagers is district hospital, which may include a hospital and a medical outpatient clinic. The types and volume of medical care in the district hospital, its capacity, equipment, staffing with medical personnel largely depend on the profile and capacity of other medical institutions that are part of the health care system of the municipal district (rural settlement). The main task of the district hospital is to provide the population with primary health care.

Outpatient and polyclinic care for the population is the most important section of the work of the district hospital. She may turn out outpatient clinic, included in the structure of the hospital, or an independent outpatient clinic. The main task of the outpatient clinic is to carry out preventive measures to prevent and reduce morbidity, disability, mortality among the population, early detection of diseases, and clinical examination of patients. Doctors of the outpatient clinic provide appointments for adults and children, make home calls and emergency care. Paramedics can also take part in the reception of patients, however, medical care in an outpatient clinic should mainly be provided by doctors. In the local hospital, an examination of temporary disability is carried out, and, if necessary, patients are referred to the ITU.

In order to bring specialized medical care closer to the residents of the village, the doctors of the central district hospital, according to the

On a divided schedule, they go to the outpatient clinic to receive patients and select them, if necessary, for hospitalization in specialized institutions. Recently, in many constituent entities of the Russian Federation, there is a reorganization of district hospitals and outpatient clinics into centers of general medical (family) practice.

The second stage the provision of medical care to the rural population is the health care institutions of the municipal district, and among them the leading place is taken by central district hospital (CRH). The central district hospital provides the main types of specialized medical care and at the same time performs the functions of a health management body in the territory of the municipal district.

The capacity of the CRH, the profile of specialized departments within it depend on the population size, structure and level of morbidity, other medical and organizational factors and are determined by the administrations of municipalities. As a rule, CRHs have a capacity of 100 to 500 beds, and the number of specialized departments in it is at least five: therapeutic, surgical with traumatology, pediatric, infectious and obstetric-gynecological (if there is no maternity hospital in the area).

The head physician of the CRH is the head of the health care of the municipal district, appointed and dismissed by the administration of the municipal district.

The approximate organizational structure of the CRH is shown in Fig. 17.2.

Methodological, organizational and advisory assistance to doctors of complex therapeutic areas, FAP paramedics is carried out by specialists from the Central Regional Hospital. Each of them, according to the approved schedule, travels to the integrated therapeutic area for medical examinations, analysis of dispensary work, and selection of patients for hospitalization.

In order to bring specialized medical care closer to the rural population, interdistrict medical centers. The functions of such centers are performed by large CRHs (with a capacity of 500-700 beds), capable of providing the population of the nearest municipal districts with the missing types of specialized inpatient and outpatient medical care.

The structure of the CRH has polyclinic, which provides primary health care to the rural population in the direction of

Rice. 17.2. Approximate organizational structure of the CRH

medical assistants of FAP, doctors of outpatient clinics, centers of general medical (family) practice.

The provision of out-of-hospital and inpatient medical and preventive care to children in the municipal district is entrusted to children's consultations (polyclinics) and children's departments of the Central District Hospital. Preventive and curative work of children's polyclinics and children's departments of the Central District Hospital is carried out on the same principles as in city children's polyclinics.

The provision of obstetric and gynecological care to women in the municipal area is entrusted to antenatal clinics, maternity and gynecological departments of the Central District Hospital.

Functional responsibilities of medical personnel, accounting and reporting documentation, calculation of statistical indicators of CRH activity do not fundamentally differ from those in city hospitals and APUs.

The third stage Providing the rural population with medical care are healthcare institutions of the constituent entity of the Russian Federation, and among them regional (regional, district, republican) hospitals play the main role. At this stage, specialized medical care is provided in all major specialties.

Regional (regional, district, republican) hospital - a large multidisciplinary medical and prophylactic institution designed to provide full specialized assistance not only to rural people, but also to all residents of the constituent entity of the Russian Federation. It is the center of organizational and methodological management of medical institutions located on the territory of the region (region, district, republic), the base of specialization and advanced training of doctors and nurses.

The approximate organizational structure of the regional (regional, district, republican) hospital is shown in Fig. 17.3.

The functional responsibilities of medical personnel, the method of calculating statistical indicators, accounting and reporting documentation of the regional (regional, district, republican) hospital do not fundamentally differ from those in city or central regional hospitals. At the same time, the organization of the work of the regional (regional, district, republican) hospital has its own characteristics, one of which is the presence in the hospital consultative clinic, where people come for help

Rice. 17.3. Approximate organizational structure of a regional (regional, district, republican) hospital

whether all municipal districts (urban districts) of a constituent entity of the Russian Federation. To accommodate them, a boarding house or hotel for patients is organized at the hospital.

As a rule, patients are referred to an advisory polyclinic after preliminary consultation and examination by regional (city) specialist doctors.

Another feature of the regional (regional, district, republican) hospital is the presence in its composition departments of emergency and planned consulting assistance, which, using the means of medical aviation or ground vehicles, provides emergency and advisory assistance with travel to remote settlements. In addition, the department ensures the delivery of patients to specialized regional and federal medical centers.

The Department of Emergency and Planned Advisory Aid works in close connection with regional center for disaster medicine.

In cases of emergencies, practical work on the fulfillment of sanitary assignments is carried out by teams of specialized medical care of constant readiness.

Unlike the CRH in the regional (regional, district, republican) hospital functions organizational and methodological department much wider. In fact, it serves as an analytical center and scientific and methodological base of the healthcare management body of the constituent entity of the Russian Federation for the introduction of modern medical and organizational technologies into practice.

The organizational activities of the department include holding regional feldsher (nursing) conferences, generalizing and disseminating best practices of healthcare institutions, organizing medical examinations of the population, scheduled visits of specialists, publishing instructional and methodological materials, etc.

Medicinal health centers are organized at enterprises with 1000 and more workers, medical assistants - up to 1000 people.

Medical units are created at large enterprises with 4,000 or more employees, and at enterprises of the chemical, coal, oil refining and mining industries - 2,000 or more.

A special role in the system of medical care for the working population in the Russian Federation belongs to medical centers at industrial enterprises.

Medical care for workers is carried out according to the workshop principle, which consists in the appointment of one position of a workshop therapist per 1500-2000 workers.

The following main tasks are assigned to health posts:

· Provision of medical care for diseases and conditions, both posing an immediate threat to the life of the employee, and in the absence of such;

· Organization of medical evacuation;

· Monitoring the health status and working conditions, including express diagnostics of the health of employees of the enterprise at the time of going to work, during work and after its completion;

· Participation in preliminary and periodic medical examinations of employees; taking measures to prevent occupational, infectious and non-infectious diseases and injuries;

· Direct participation in the organization of first aid and evacuation in the event of various emergencies and the elimination of medical consequences of emergencies at the enterprise.

Preventive work plays an important role in the activities of shop therapists. It can be effective only under the condition of a proper study of the characteristics of a given production and working conditions of workers, as well as knowledge of a specific occupational pathology. Based on the study of technological and sanitary-hygienic features of production, doctors of the medical unit develop appropriate measures to reduce the incidence of illness and industrial injuries.

In the Russian Federation, a little less than 30% of the country's population lives in rural areas.

Medical care for the rural population is based on the basic principles of healthcare organization. However, the factors that determine the differences between the city and the countryside affect the organizational forms and methods of work of rural medical institutions: the nature of the settlement of residents, the radius of service, the seasonality of work, the impact of weather conditions during field work, the specific conditions of the labor process, the disorder of household and household activities. conditions, regional and national characteristics and customs, educational and cultural level, etc.

The main features of the organization of medical care for the rural population of Russia were and are at present:

Stages;

The presence of special medical and preventive institutions in the structure of rural health care;

Special organizational forms and methods of work of medical personnel and health care facilities in general.

Conventionally, there are 3 stages of providing medical care to rural residents. The main organizational forms of medical care are inpatient and traveling.

The first stage is a rural medical area, covering an area with a radius of 5-10-15 km (in different regions of Russia) and including the following health facilities: a rural district hospital, a medical outpatient clinic, paramedic and paramedic-obstetric first-aid posts, health centers, at industrial and agricultural enterprises, nurseries - gardens, etc. At this stage, rural residents receive qualified medical care (therapeutically, surgical, obstetric and gynecological, dental, in some cases - pediatric). These conditions are most consistent with the observance of the principles of general medical practice and family medical and social services.

FAP is organized in settlements with a population of 700 or more, with a distance of at least 5 km to the nearest medical institution, and at a distance of more than 7 km from the nearest medical institution, a FAP can be organized in settlements with a population of 300-500 people.

The main tasks of the FAP are: providing first aid and conducting sanitary and recreational and anti-epidemic measures aimed at preventing diseases, reducing morbidity and injuries, and improving the sanitary and hygienic culture of the population. The FAP paramedic provides first aid for acute illnesses and injuries, carries out vaccination work, physiotherapeutic measures, and fully fulfills the doctor's prescription, organizes the patronage of children and pregnant women, under the direction of the doctor conducts preventive, anti-epidemic and sanitary and hygienic measures.

The next second stage of providing the rural population with medical care is the district link, headed by the central district hospital (CRH), CRHs are available in all district administrative territories. Each district center has a center for state sanitary and epidemiological surveillance (GSEI). In the structure of health care in districts, such may be interdistrict specialized centers, numbered hospitals, dispensaries, health centers, health centers, district and city hospitals, etc.

The third stage (level) of medical care for the rural population is regional health care institutions located in the regional center (regional hospital with an advisory clinic, dispensaries, dental clinic, regional center of state sanitary and epidemiological supervision, etc.). At this stage, highly qualified medical care is provided in almost all specialties.

Features of the provision of primary health care to women.

Order number 50 (most likely!) Write to Olya, who will throw off the material during the exam

Organization of primary health care according to the principle of general practice (family medicine).

Family medicine is the observation and treatment of a patient throughout his life.

The main advantages of the family medicine system:

Holistic approach to the health of monitored families;

Accessibility and convenience of treatment;

Possibility of early diagnosis of serious and life-threatening diseases;

Home visit to the patient;

Prophylaxis;

Providing psychological assistance to the patient and his family.

Family medicine is the most effective medical consultation, as a doctor

Observes the patient and his environment for a long time;

Treats the patient individually in a comfortable and familiar environment (at home or in his office);

Knows the patient's entire family, easily builds relationships;

If necessary, appoints the patient to a narrow specialist.

The general practitioner is the first to see the patient, assess his condition, and make a preliminary diagnosis. This specialty - a general practitioner - combines biological, clinical disciplines and psychology, which allows to provide continuous and comprehensive assistance to a person and his family.

The general practitioner treats people of all ages, he is not limited by the narrow framework of one discipline, thus he provides a comprehensive and individual approach to the patient. The family doctor can be addressed with questions not only of a medical nature.

The main activity of the General Practitioner Department is working with families. The main goals of the family nurse's work are to preserve the health and prevent diseases in their wards. The family nurse must take into account the factors that negatively affect the health of the wards: smoking, alcohol abuse, drug addiction, as well as occupational hazards. A family nurse should be competent in the humanities - be a good teacher and psychologist. To carry out manipulations (massage, physiotherapy, etc.).

Among the organizational principles of modern public health, one of the important is the observance of the unity and continuity of medical care to the population in urban and rural areas. In general, medical support for the rural population is characterized by limited availability of medical care and low efficiency of medical, social and preventive measures. The main reasons for the deterioration of medical care in rural areas are: limited funding; outdated organizational forms of support ...

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Mikhalyuk S.F.

RURAL POPULATION MEDICAL SERVICE ORGANIZATIONS.

The main factors contributing to the persistence of differences in medical services between urban and rural populations are:

peculiarities of population settlement;
peculiarities of agricultural labor (seasonality, low level of mechanization, high proportion of manual labor, often considerable remoteness of the place of residence from the place of work, etc.);
outflow of young people and people of working age to urban areas;
aging of the population in rural areas;
lower living standards in rural areas;
socio-economic and everyday difficulties.

In general, medical support for the rural population is characterized by limited availability of medical care, as well as low efficiency of medical, social and preventive measures.

The main reasons for the deterioration of medical care in the countryside are:

limited funding;
outdated organizational forms of providing medical care;
weak material and technical base;
lack of personnel, transport, communications;
high cost of drugs;
violation of continuity at different stages of medical care.

In this regard, the task of converging the levels of medical care to the urban and rural population remains relevant to this day.

The goal of reforming the system of organizing medical care for the rural population is to preserve and develop the state health care system, ensure social justice in the field of health care, ensure affordable and high-quality medical care, as well as increase its effectiveness.

The key directions for the development of health care in the countryside are:

Preservation of a unified state health care system.
Improving the health of the population by improving the living standards of rural residents and improving environmental conditions.
Optimization of personnel policy in rural areas and development of programs for social development and protection of health workers. Improvement of medical and sanitary legislation with the aim of securing medical workers in the countryside, restoration and provision of a minimum of benefits (free housing, heating and lighting, seniority benefits, advanced training, etc.)
Improving the work of mechanisms for effective allocation of resources by supporting priority areas in the activities of rural health organizations (introduction of the institution of a general practitioner).
Strict adherence to the medical and organizational principles of the formation of a network of institutions in the countryside, taking into account the population's need for medical care and the prospects of the medical, demographic and medical organizational situation.
Improving the structure and functions of rural health care organizations.
Ensuring continuity in the work of the rural district network and specialized services.
Development of primary accounting and reporting documentation, examination of its feasibility.
Creation of institutions of medical and social assistance (with a rehabilitation bias) for the elderly, disabled and elderly people in local hospitals with joint financing of these beds by health care and social protection services.
Expansion of medical and social assistance in outpatient clinics and at home.
Giving the health care system the status of the main system that establishes the corresponding requirements for other sectors of the national economy according to the criterion of their impact on the health of the population and ensuring a favorable living environment.

For a number of years, there has been a negative "growth" of the population with an excess of mortality over births. The age structure of the population has changed towards aging. In the Republic of Belarus, the share of people over 60 years old is 19.0% (in the countryside - 31%, in cities - 14%.

In 2003, 44.9% of inpatient and outpatient clinics were located in adapted premises. About half of the hospitals and outpatient clinics did not meet sanitary standards. In dilapidated and emergency buildings there were 125 buildings for various purposes of healthcare organizations, incl. in emergency-dangerous - 22. in 148 hospitals and 232 outpatient clinics, stove heating, 37% of hospitals did not have hot water supply, and 2% - and cold.

The main goals of social reforms in the field of health should be:

ensuring conditions for compliance with constitutional guarantees for the provision of medical care to the population and control over sanitary and epidemiological well-being;
ensuring the sustainability of the functioning of healthcare institutions, changing the volume and procedure for financing the industry;
increasing the economic and clinical efficiency of the use of financial, material and human resources of health care;
ensuring the protection of the patient's rights to receive timely and high-quality medical care;
integration into the world community.

Healthcare management in the republic is carried out according to a three-level principle:

the strategic level, which is represented by the ministry of health and public authorities; they make legislative and regulatory decisions (laws, decrees, decrees, orders, orders), that is, they determine the strategy of the industry for the future, binding on execution and management;

the tactical level, represented by the territorial regional authorities, which are guided by the provisions and orders of the strategic level. Their most important function is to coordinate the activities of territorial health systems;

the operational level, which includes the management of health care facilities, their structural divisions and services.

The organization of medical and preventive care for the rural population is based on the same organizational principles as for the urban population.

Basic principles of health care:

state character;
planning;
free;
general availability;
preventive focus;
connection with science;
public participation in health protection.

The main task of rural health care is to fully meet the needs of rural residents in all types of medical care.

The main feature of the organization of medical care for the rural population is the staging of its provision. The essence of the phasing principle lies in the fact that at each of the subsequent stages, patients are provided with appropriate medical care, which could not have been provided to them at the previous stage.

The classical scheme of organizing medical care for the rural population is presented in three stages:

Stage I. Rural medical area: Have private hospital, which includes a hospital, an outpatient clinic, a day hospital, feldsher-obstetric points, a pharmacy.Medical outpatient clinicin its composition has the same subdivisions with the exception of the hospital.

Stage II. Central District Hospitalas part of a hospital for adults and children, specialized departments, an advisory clinic, an organizational methodological office.

The regional center for hygiene and epidemiology (RCHE) and the regional pharmacy work in close contact with the central regional hospital.

Stage III. Regional, republican hospital,which includes a hospital with specialized departments, an advisory clinic and an organizational and methodological department; department of emergency and planned consultative medical care;

Regional specialized institutions(oncological dispensary, anti-tuberculosis dispensary, blood transfusion station, etc.);
Regional Center for Hygiene and Epidemiology;
Clinics of medical and research instituteslocated in the regional center;
Regional Pharmacy Administration.

Consider some of the features that are typical for the population living in rural areas

Features of the work of the rural population.

Seasonality of work (affects the appeal for medical care: 45% - winter, 25% - spring, 10% - summer, 20% - autumn).
Influence of meteorological (weather) factors (work outdoors).
Frequent change of work steps.
Conducting work over significant distances.
Features of physical activity.
Special temporary mode of operation (from dawn to dawn, milkmaids).
Features of the mechanization of rural labor
Dust, noise, vibration.

Features of the habitat.

Contact with biological objects (animals, insects).
Influence of environmental factors (chemicals, fertilizers, nitrates, etc.)
Sanitary and hygienic problems (water supply, personal hygiene, etc.).
Problems of transport accessibility, specificity of settlement, communications, incl. and medical care.
Power supply features;
Seasonal vitamin imbalances.

3. Socio-psychological characteristics.

Feelings of community and loneliness.
Traditions of the "joint society" Smoking and alcoholism ..
Complex of the "collective farmer".

4. Features of the demographic characteristics of the rural population.

Children and adolescents under 18 years old - 5-30%.
Average age (18-60) - 4 - 20%.
Elderly and senile (60 and more) - 50-80%.

5. The composition of the family.

Families of 1 person - 5-20%.
Families of 2 people - 15-40%.
Families of 3 people - 15-30%.
Families of 4 people or more - 5-10%.

The health status of the rural population is determined by:

For the analysis of health status, WHO recommends using:

Vital registers, i.e. demographic data;
Census results;
Current information from health services;
Epidemiological surveillance data;
Selective, or screening, studies;
Disease registers;
Other sources (including those not related to health care).

Morbidity of the rural population according to the data on the use of medical facilities.

The leading reasons for the appeal of the rural population are: respiratory diseases - 30-35%, circulatory system - 20-30%, digestive organs - 10-20%, neoplasms - 5-8% per thousand population. It is natural that the appealability for individual diseases varies significantly depending on the demographic characteristics, regional characteristics (Chernobyl).

Morbidity of the rural population according to the data of preventive medical examinations:

1.Diseases of the nervous system and sensory organs - 25-30%.

2. Respiratory organs - 25-30%.

3.Cardiovascular system - 10-40%.

4.0 digestive organs - 6-12%.

Morbidity of the rural population according to hospitalization data

The structure of hospitalized patients and the duration of inpatient treatment is determined by the age and gender structure.

Children under 16:

pneumonia and tonsillitis;
ARVI;
infectious diseases.

Average age (17-55 years old):

diseases of the nervous system and sensory organs;
respiratory diseases (men) and gynecological diseases (women);
diseases of the digestive system.

Elderly and senile age (55 years and older):

cardiovascular diseases;
respiratory diseases (COPD);
neoplasms.

Characteristics of visits to medical workers in rural areas.

1. Medical advisory- 57%, of which: a) therapeutic profile - 35-55%; b) dental - 20-30%; c) pediatric - 10-15%; d) surgical - 10-15%.

2. Dispensary - 18%, of which: a) therapeutic profile -50-65%; b) pediatric - 25-35%; c) surgical - 10-15%.

3.Preventive- 25%, of which: a) pediatric - 25-30%; b) dental - 20-25%, d) obstetrics and gynecology - 15-25%, therapeutic - 10-15%.

Pre-medical and first medical aid to the rural population is provided in the institutions of the rural medical district. For the villagers, this is the first stage of medical care - the closest and most accessible link in the health care system.

Rural medical area- functional education, which is the main organizing link of communication between PHC and all specialized types of medical care at its different stages. The average population is 5-7 thousand people, the average service radius is 8-15 km.

A rural medical area is an area with a living population, served by doctors of a medical organization located on it. The territory of the IED usually corresponds to the boundaries of rural administrative units (one, less often two village councils). At the SVU, either rural district hospitals with outpatient clinics or independent rural medical outpatient clinics are organized. The work of these institutions is supervised by chief physicians - respectively, the chief physician of a rural district hospital or the chief physician of a rural medical outpatient clinic. All rural medical institutions deployed in a rural medical area (FAPs) are subordinate to them.

The village in which the district hospital (outpatient clinic) is located is called the point. The distance of the most distant village from the settlement village is called the radius of the site.

Tasks of the rural medical department (district hospital, rural medical outpatient clinic):

providing medical and preventive care to the population;
introduction into practice of modern methods of prevention, diagnosis and treatment of patients;
development and improvement of organizational forms and methods of medical care for the population, improving the quality and efficiency of medical and preventive care;
organization and implementation of a set of preventive measures among the population of the site;
carrying out medical and preventive measures to protect the health of mothers and children;
study of the causes of general morbidity and morbidity with temporary disability and the development of measures to reduce it;
organization and implementation of medical examination of the population, especially children, adolescents;
implementation of anti-epidemic measures (vaccinations, identification of infectious patients, dynamic monitoring of persons who were in contact with them, etc.);
implementation of current sanitary supervision over the condition of production and communal facilities, water supply sources, children's institutions, catering establishments;
carrying out treatment and prophylactic measures to combat tuberculosis, skin and venereal diseases, malignant neoplasms;
organization and implementation of measures for sanitary and hygieniceducating the population, promoting a healthy lifestyle, including rational nutrition, increasing physical activity; combating alcohol consumption, smoking and other bad habits;
wide involvement of the public in the development and implementation of measures to protect the health of the population.

In accordance with these tasks, the duties of the doctor (doctors) of the rural medical district have been developed:

A special place in the professional activity of a doctor in a rural medical district is occupied by the protection of mothers and children. If there are two or more doctors in a rural medical outpatient clinic or rural district hospital, by the order of the chief doctor, one of them is responsible for the medical care of children at the district.

Feldsher-obstetric station (FAP).(1990 - 3012.2000 - 2848 (-164) 2005 - 2524 (-324) ((Σ ... - 488) decreasing trend).

Feldsher-obstetric stationis a specific feature of rural health care and occupies a very important place in providing the rural population with medical care.

Feldsher-obstetric points are outpatient clinics. Their creation is caused by the peculiarities inherent in rural health care - the need to bring medical care closer to the population in the conditions of a large service radius of the district hospital (outpatient clinic) in relation to all existing settlements.

It is organized in villages with a population of 700 or more and a distance of more than 5 km to the nearest medical organization, 300-700 people and a distance of more than 5 km, less than 300 people and a distance of more than 6 km.

Headed by a paramedic, midwife and nurse.

FAP tasks.

improving the sanitary and hygienic culture of the population;

providing the population with first aid medical care, fulfilling the doctor's prescriptions;

Providing medical care in case of acute diseases and accidents;

active patronage of women and children; health education

participation in the current sanitary supervision of institutions for children and adolescents, utilities, food, industrial and other facilities, water supply and cleaning of populated areas;

conducting house-to-door rounds according to epidemic indications in order to identify infectious patients, persons in contact with them and those suspected of infectious diseases;

sale of drugs.

The FAP is managed by the hospital or outpatient polyclinic organization to which it is subordinate.

FAP should have premises that meet the sanitary and hygienic requirements and tasks of the institution.

An important area of the FAP's activity is strengthening the health of mothers and children. To implement it, the FAP is assigned the following functions:

wide dissemination of information on family planning methods;

early identification of pregnant women;

registration of pregnant women;

patrons and dynamic observation of women during pregnancy and after discharge from the maternity hospital;

differentiated observation and service of newborns, premature and physically weakened children, especially children of the 1st, 2nd - 3rd year of life;

Direction and content of FAP activities

Sanitary and anti-epidemic work	Medical and preventive care for the adult population	Medical services for women and children
Current sanitary supervision	Outpatient appointment, home help	Monitoring pregnant women and women in labor
Anti-epidemic measures in the outbreak	Providing first-aid medical care	Psychoprophylactic preparation of pregnant women for childbirth
	Participation in medical examinations and medical examinations	Providing assistance to women in labor and parturient women
Measures to reduce occupational morbidity	Execution of medical appointments	Provision of medical care to gynecological patients
Prophylactic vaccinations	Medical and sanitary services for the population during the field work	Dispensary supervision of children. Provision of medical and preventive care for children.
Working with a sanitary asset		Prevention of rickets, control over rational nutrition, physical development of children.

Currently, the share of FAP participation in providing medical and preventive care to villagers is still high, since it serves a significant number of the population, is the closest, most accessible type of medical care, especially to residents of remote villages. Depending on the remoteness of the settlement from the outpatient clinic, district hospital or central district hospital, the share of rural residents' appeals to FAPs ranges from 30 to 40% or more of the total referral rate.

Conclusions:

FAP is one of the most affordable and popular types of medical services for the rural population.
FAPs play an important role in providing medical and preventive care to rural residents.

FAP documentation: 1) patient admission log; 2) a journal of suggestions and comments of the doctor (specialists); 3) schedule of doctors' departure. The rest of the documentation is determined by the management of SMS, IAS, CRH.

Rural outpatient clinic (SVA).(1990 - 319.2000 - 418 (+ 99). 2005 - 589 (+ 171) ((Σ ... + 270) upward trend).

Rural medical outpatient clinicis the primary link in the system of social and hygienic, medical and preventive, and sanitary and anti-epidemic provision of the rural population.

Organizes and provides first medical and first aid medical assistance.

The tasks of the IAS are the tasks of the VCA. The staffing structure depends on the number of people served. Typically 1 general practitioner per 1,300 adults, 1 pediatrician per 800 children. Dentist - 1 position for 1.5 positions of a doctor. Positions can be combined for several IAS or SMS (then work on schedule)

Medical documentation: in full volume of an outpatient clinic.

Specificity: I) Log of the departure of the main specialists;

2) Schedule of the departure of the CRH specialists.

Rural district hospital- is the main medical institution of the SVU.(SUB 1990 - 447 - with the number of beds 15270. In 2000 - 388 - 11501. In 2002 - 346 –9990 + 1 nursing care center with the number of beds 15. In 2003 - 302 –9475 + 4 nursing care units with the number of beds 100. In 2004 - 221 - 6019 + 47 nursing care centers with 990 beds. In 2005 - 184 with 5056 beds + 90 nursing care units with number of beds 2017 - a tendency to decrease).

Depending on the radius of service, the size and density of the population, rural district hospitals are divided into 4 categories:

Category I - 75-100 beds. Such a district hospital should have specialized beds for therapy, surgery, obstetrics, pediatrics, infectious diseases, and tuberculosis. As a rule, such a hospital has an X-ray room.

The volume of outpatient care is most often the same as in CBA. However, it can be additionally:

surgical, obstetric-gynecological, etc. The diagnostic capabilities are significantly increased: the X-ray biochemical laboratory.

More than 100 beds are usually already a village or district hospital. Service radius is usually up to 15 km., Population 5 thousand and more

SMS tasks:

1) the tasks of the VCA

2) organization of inpatient medical care for the population;

3) analysis of the use of hospital beds and work aimed at improving the efficiency of its use;

4) prevention of intra-hospital infections;

5) organization of hospital meals;

6) hospital management (utilities, transport, landscaping, fire-prevention measures, logistics, etc.).

7) medical and social function;

Medical documentation: full documentation of outpatient and inpatient medical institutions.

Features of the analysis of the work of the SMS: 1) terms of hospitalization;

2) the seasonality of hospitalization; 3) repeat hospitalization;

4) the distribution of hospitalization rates by days of the week. 2/3 of the budget is spent on inpatient care.

SUB provides inpatient care, performs medical and social functions; on its own territory should almost completely satisfy the need for first aid, first aid.

Territorial Medical Association (TMO).Central District Hospital (CRH).(1990 - 137 with 37397 beds, 2000 - 137 - 33796, 2005 - 1 26 with number of beds 2 6889)

The central district hospital is the main institution for the provision of qualified medical care. At the same time, the Central Regional Hospital is the center of the organizational and methodological management of the health care of the region.

By capacity, CRHs are divided into 5 categories:

The capacity of the Central District Hospital and other structural medical institutions is determined by the average annual number of beds deployed. Regardless of the bed capacity, the size of the population served and the radius of service, the CRH must have a certain list of structural units:

polyclinic;

a hospital with medical departments for the main medical specialties;

admission department;

treatment and diagnostic departments (offices) and laboratories;

organizational and methodological office;

department of emergency and emergency medical care;

utility block (catering, laundry, garage, etc.).

if the district center does not have an independent children's hospital with a consultation and a dairy kitchen, a maternity hospital with an antenatal clinic, then women's and children's clinics and a dairy kitchen, as structural units, are included in the outpatient clinic of the Central District Hospital.

In the CRH, the principle of one-man management is implemented in the person of the chief physician of the CRH (TMO). Under the chief physician, a medical council is created, there is a certain number of deputies, a chief accountant, and a chief nurse.

Peculiarities:

is a legal entity;

is the manager of funds;

has public management structures (medical council, council of paramedics, council of nurses, etc.).

makes organizational and managerial decisions;

has specialized departments;

has an organizational and methodological cabinet (department);

has an ambulance service;

departments (services) can perform inter-district functions;

has chief specialists;

In the district, in addition to the Central District Hospital, specialized dispensaries (anti-tuberculosis, dermatovenerologic) can be organized, which work as interdistrict institutions (serving the population of nearby districts). In the enlarged districts, which have arisen as a result of the unification of two or more districts, the former district hospitals continue to function, which retain all their functions, organizational structures and standards of service to the population.

In each region of the republic, institutions of the sanitary and anti-epidemic service are also organized and operate - regional centers of hygiene and epidemiology (RCHE). The settlements located around the district center and served by the district medical institutions (polyclinic or CRH) are called the assigned areas.

The tasks of the TMO:

1) providing the population with the required amount of highly qualified inpatient and polyclinic medical care;

2) operational and organizational and methodological guidance, as well as control over the work of all healthcare institutions and individuals engaged in individual medical activities in the district;

3) planning, financing and organization of material and technical supply of health care institutions of the region;

4) planning and implementation of measures for the development of a network of medical institutions;

5) development and implementation of measures aimed at improving the quality of medical services for the population of the district, reducing morbidity, disability, hospital mortality, infant and general mortality and improving the health of children, adolescents and women;

6) timely and widespread introduction of modern methods and means of prevention, diagnosis, treatment and rehabilitation into the practice of all health care facilities of the district;

7) development, organization and implementation of measures for the placement, rational use, professional development and education of medical personnel and other personnel of health care institutions of the district;

8) hospital management.

The chief physician has a certain number of deputies:

1) Deputy for Medical Services - oversees the organizational and methodological support of the work of the district health care facility, oversees the work of chief specialists;

2) the deputy for the medical part - supervises inpatient medical care, the ambulance service;

3) Deputy for outpatient work - oversees outpatient and outpatient medical care;

4) Deputy for medical and rehabilitation expertise - oversees the incidence of temporary and permanent disability, all types of expertise;

5) Deputy for Childhood and Obstetrics - oversees issues of protection of mothers and children;

6) Deputy for administrative and economic work - oversees the issues of material and technical support for the work of the health care facility.

Regional level of medical care.

The leading medical and prophylactic institution, organizational, methodological and consulting center of health care in the region is the regional hospital, for the children's population - the regional children's hospital.

Regional hospital structure:

a hospital with an admission department (specialized departments);

consulting clinic (may be separate);

treatment and diagnostic departments, offices, laboratories;

organizational and methodological department and department of medical statistics;

departments of emergency and planned consulting assistance;

X-ray and radiological department;

pathological department;

business units (catering, warehouses, etc.).

The tasks of the regional hospital:

provision of advisory, specialized or qualified medical care that cannot be provided in other medical institutions of the region;

assistance to regional healthcare institutions and authorities in improving the quality of medical and preventive work in the field, generalizing best practices and improving the forms and methods of medical activity;

coordination of medical and preventive and organizational and methodological work carried out by all specialized medical institutions of the region;

the allocation of air ambulance and ground transport for emergency and planned counseling for patients;

a systematic analysis of the health status of the population of the region and the activities of medical and preventive institutions, the development, together with the chief specialists of the regional health department, of the necessary measures to reduce the incidence and improve the quality of medical care.

On the basis of regional hospitals, retraining courses for advanced training of medical workers of the region can be conducted. The bed capacity of the regional hospital depends on the population of the region. The average capacity of a regional hospital in the Republic of Belarus is 1000 beds.

In all regions, specialized dispensaries are organized (anti-tuberculosis, oncological, etc.). as well as other specialized medical institutions (regional psychiatric hospital), which are regional centers for the provision of specialized medical and organizational and methodological assistance.

Separately, it is necessary to dwell on the features of some types of medical hybrid for the rural population.

Ambulance in the countryside.

At the level of FAP, SUB, SVA it is provided by the medical personnel of these institutions at any time of the day.

The most important issues in the organization of emergency and emergency medical care for the rural population are:

1) the availability of a schedule and procedure for the provision of this type of medical care in all rural health care facilities;

2) the presence of styling, bags and their necessary equipment;

3) the presence of algorithms for the provision of emergency medical care in all medical facilities and, first of all, in the dispatch service of the ambulance, fixing the arrival of calls and the measures taken;

4) due continuity (based on the principle of feedback) between the ambulance service, outpatient clinic service, dispatching services of farms and enterprises;

5) training the population to provide self and mutual assistance, to improve the health literacy of the population;

6) the development and availability of incentives for participation in this type of assistance for all health workers, incl. and nursing staff;

7) training of medical personnel to provide emergency and emergency medical care;

8) the priority of medicinal and material and technical support for this type of medical care.

Nursing staff in the rural health care system.

In rural areas, it plays a very significant role in the provision of medical care and other tasks of protecting the health of the population.

Therefore, it is necessary to plan and implement:

1) continuous training of nursing staff using all types and methods of training;

2) preparation and training for making an independent medical decision;

3) expansion of functions and rights, delegation of powers, participation in all types of medical activities of the health care facility.

Features of the organization of the provision of medical care to the rural population.

1. Phase.

2. Exit forms of work.

3. Development of general medical practice

4. The high role and importance of nursing staff. 5. Combination of treatment-and-prophylactic and sanitary-anti-epidemic measures.

6. Development of hospital-replacing technologies.

5. Medical and social nature of the organization of work.

7. Priority of organizational work with local governments.

8. Development and implementation of telemedicine.

All the rest of the features are due to the socio-economic situation and the quality of work of executives in the health care system at all levels.

PAGE 6

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