Satisfactory of Health Care in the context of transformations of medical sector in Russian Federation
Laissan Moucharyamova1 Irina Kuznetsova-Morenko2
Abstract
The National Project "Health" was the main political measures are transforming the healthcare system of Russia. The paper addressed the impact of the reform on accessibility and efficiency of the health services transferred to municipal budgets, evaluated economic and social risks of the reforms.
Analyzing the existing methods of measurement of public assessments of quality of medical care we approve that there is luck of the effective means: the date of surveys conducted by local ministers of health care are differ from the date of independent surveys which from another hand don't have permanent character and specific random. The health care system still has not public feedback and evaluation of the medical care but the problem of public control a quality of health care system is established both on the state level and on the level of consumers of medical service.
1	Professor, Chief of the Department of History, Philosophy, Sociology and Policy Studies,
vice-rector, Kazan State Medical University, Russian Federation.
2	Assistant Professor of the Department of History, Philosophy, Sociology and Policy
Studies at Kazan State Medical University, chief of the Department of Quality Studies of the Center of Advanced Economic Studies of Academy of Sciences of Tatarstan, Russian Federation.
Introduction
Structural transformations in economic and social life in Russia after Perestroika were followed by tragic reactions by demographical processes. The total number of population of Russia is in stable decreasing - now the population of country (148.6 million people on January 1, 2009) declined by 8.5 % comparing 1992 year. The level of diseases was increasing all the time - so if in 1990 it has been registered 158.3 million patients (or 1070 on 1000 persons of resident population), in 2004 - 204.2 million patients (1432). In 2006 it has been registered 216.2 million patients (1517 counting on 1000 persons), including 108,8 million patients with the diagnosis established for the first time in a life (764). Thus, the general disease has increased by 36.6%. Thus disease, taking into account population reduction, has increased in a greater degree: the general - on 41.8 %, primary - on 17.4 %3. The main factors of that processes was decrease of a level and quality of life, but also healthcare was not ready to correspond the necessity to improve the quality of treatment and prophylactic.
From the spring 2004 the issue of quality and accessibility of healthcare become a significant part of a course of social modernization of Russia when President Vladimir Putin in the Message to Federal Meeting has concentrated attention to the most essential for citizens of the country problems - quality and availability of health services, formation, habitation and has planned ways of social modernization, and by autumn of 2005 the government has been declared "national projects" in the
3 Sherbakova E. V 2008 godu estestvennaja ubyl' naselenija snizilas' do 364 tysjach chelovek, i nemnogo vyrosshij migracionnyj prirost kompensiroval ee na 2/3. Demoscope weely. ^ 367 - 368, 2 - 15 March 2009. URL: http://demoscope.ru/weekly/2009/0367/barom02.php; Sherbakova E. Zabolevaemost rossiyan rastet. Demoscope weely. ^ 241 - 242. 3 - 16 April 2006. URL: http://demoscope.ru/weekly/2006/0241/barom01.php;
same spheres4.
The Russian government in 2008 declared expansion of the priority national project in sphere of public health services which will concern the measures directed on decrease of death rate from the operated reasons. It gives the grounds to assume that, according to heads of the country, organizational actions for realization of problems of the first stage of the project are carried already out. Therefore now it is expedient to address to those estimations, which experts and the population give to the received results.
4 The basic directions of the priority national project in public health services sphere concern:
-	Development of the primary sanitary help which provides following actions:
*	preparation and retraining of doctors of the general (family) practice, local doctors-therapists and podiatrists;
*	wages increase to medical workers of a primary link, accoucheur cabinets and "first aid" cabinets;
*	strengthening of material base of diagnostic service of out-patient-polyclinic establishments, the first help, female consultations;
*	preventive maintenance of a HIV-infection, hepatitis, revealing and HIV-infected treatment;
*	additional immunization of the population within the limits of a national calendar of inoculations;
*	introduction of new programs of inspection of newborn children;
*	additional prophylactic medical examination of the working population;
*	rendering of medical aid to women in pregnancy and sorts in state and public health services municipal authorities.
-	Maintenance of the population with hi-tech medical aid:
*	increase in volumes of rendering of hi-tech medical aid;
*	building of the new centres of high medical technologies, preparation for these centres of highly skilled doctors and the average medical personnel (Directions, main events and parameters of priority national project "Health". Affirmed by presidium of Council at the President of Russian Federation for realization of priority national projects (deed # 2, 21 December 2005).
"Health": a national project in the context of system problems of the sector in Russian Federation
The purpose of the initial stage of the National Project "Health" was the development of primary medical and nursing care. The need for this initiative was explained by the fact that the national public health was traditionally orientated towards development of hospital-based medical care, which has lead to underfinancing of primary care, including lack of distinct doctors, undersupply of diagnostic equipment in outpatient clinics, and general low quality of primary care. As a result, the rates of chronic and undercared for diseases have steepened, leading to increased levels of hospitalization and emergency calls. The information about international success in the field of primary care has given additional support to this initiative. The results from research show that indicators of population health and general level of satisfaction with health care are higher in the countries where primary care institutions are given priority, and are significantly lower in the countries where they have not received such development. At the same time, the former group of states (like UK and Finland) has, as a rule, lower healthcare expenditure rates per citizen, than the latter (USA, Germany)5.
Therefore, the national project was focused on training general practice and family doctors, as well as district doctors - physicians and pediatricians, as well as increase in salaries in primary and acute care, and allocation of additional resources to diagnostic services in ambulance stations, polyclinics, emergency stations, and maternity welfare centers.
It should be noted, that the similar tasks were already posed before the Russian healthcare system. The Government of Russian Federation has
5Starfield B., Shi L. (2002) Policy relevant determinants of health: an international perspective. Health Policy. 2002. m 60: P. 201-218.
adopted "The concept of development of healthcare and medical science in Russian Federation", which covered the period from 1995 to 2005. Most of the propositions of this document still retain their urgency and significance to the present day. The tasks of the Concept very much resemble the ones put forward by the National Project. They have similar orientation towards development of primary medical and nursing care, and of the institute of general (family) practice doctors, increase of preventive care measures share in healthcare, reduction of recovery period through implementation of state-of-the-art methods of diagnosis and treatment, full access to healthcare services for population, integration of medical practice and research, improvement of legal regulation base, rise in the levels of social security and salaries of healthcare workers, increased role of professional medical associations and many other issues. The Concept provided for increase of healthcare financing share up to 6-7% of GDP. Unfortunately, as specialists remark, practically none of the points of the Concept were fulfilled6. In 10 years (1995-2005), mortality rates have grown from 15.0 to 16.1% per thousand of population. Experts see the main reason of failure in "lack of program-targeted orientation. It lacked concrete targets7, which were to be implemented and accountability for their performance. It lacked resources necessary for cost-effective achievement of these targets and adequate control measures of implementation process were not set." 8 It is quite clear, that the possible failure of another healthcare modernization project can have most serious negative effects.
Of course, National Project did not solve, and even could not solve the system problems of Russian healthcare. The proposed measures resembled technologies used in "emergency care", rather than consistent
Aganbegian A.G., Varshavskij Yu.V., Zhukovskij V.D. (2007) O programmno-tselevom upravlenii v zdravookhranenii. SPERO 2007. ^7. ^.5. URL: http://spero.socpol.ru
7	Ibid.
8	Ibid.
institutional change. This fact gives certain grounds for various experts to characterize the project as "a repair of holes and renewal of the fagade"9, or to state that "changes in the work of ambulance and polyclinic institutions proceed rather in an evolutional way, while reorganization of bed stock in healthcare has a 'revolutionary' character"10.
Simultaneously with implementation of the priority project measures, under the requirements of the Federal Law on distribution of power between federal center, subjects of the federation and local administration, the distribution of power in healthcare services was introduced. The local municipal level was made responsible for management and financing of only acute care (except sanitary aviation), primary medical and nursing care at in-patient polyclinic and clinical institutions, antenatal and postnatal medical care. The level of federation subjects is assigned with formation of budget expenditures of the subjects in the part of specialized medical help (antituberculous, dermatovenerologic, narcological, oncological, donor blood supply). The responsibly for development of the advanced technology medical care was imposed on the federal level. In essence, Russian healthcare has subdivided in two separate systems: state (federal and regional) and municipal.
Initially, these innovations have received unwelcome reception both from the experts and the medical professionals. Specialists of the Civic Chamber of the Russian Federation have investigated the state of healthcare in minor cities on the basis of information submitted by 79 heads of administration of minor cities in summer 2007, and stated that:
Gontmakher Ye.Sh. (2007) Natsionalnye proekty: pervye itogi realizatsii. SPERO 2007. ^7. P.122. URL: http://spero.socpol.ru
10 Abashev A.R., Gainutdinova L.I. (2008) Nekotorye aspekty okazanija lechebno-profilakticheskoj pomostchi naseleniju na sovremennom etape, problemy i puti ikh reshenija. Gorodskoe zdravookhranenie. 2008. ^ 4. ^.34
The division of healthcare system into federal, regional and municipal has aggravated the state of municipal healthcare, creating the situation of inferiority and third-quality of the latter, contributing to the even more pronounced residualbased financing. There are problems with timely inpayments planned in the annual budget11.
Federal level has not developed a considered plan of municipal healthcare development. As a result, as it is stated by the members of the House of Commons of Russia, "some regions invent their own approaches, while others, without any certain instructions, do not know what to do whatsoever, and have let it just go. Some transform Attendance and Midwifery Stations in stations of general medical practice; others close ambulances and rural district hospitals, without provision of another adequately full system of health care service for the remainder of population, often few in number"12.
According to the estimates of the specialists, in 2006 financing of the National Project in healthcare has grown only by 0.25% of GDP. Therefore, the situation with underfinancing of the sector has not experienced principal changes: in absolute figures healthcare expenditure per head in RF is 40 times lower than in USA, 20-30 times lower than in Western Europe, 6.5 times lower than in Czech Republic, and 1.9 times lower than in Turkey13.
11	Analiz sostojanija zdravookhranenija v malykh gorodakh i predlozhenij po ego uluchsheniju na osnove analiza informatsii, postupivshej ot 79 glav administratzij malykh gorodov (proveden spetzialistami obschestvennoj palaty Rossijskoj Federatzii). URL:
http://medvestnik.ru/2/0/8548.html
12
Komissija po voprosam zdravookhranenija obsudila problemu finansirovanija otrasli I podgotovki kadrov.URL:
http://oprf.cmmp.ru/rus/news/chamber/6a9aeddtc689c1doe3b9ccc3ab651bc5/#1
13
Akchurin R.S., Ulumbekova G.E. Nedofinansirovanie zdravookhranenija - udel
Healthcare has not become a priority issue in the regions either. According to official data of the Ministry for Healthcare of the Republic of Tatarstan (MH RT), in one of the most economically developed regions of RF healthcare financing share is 2.4% of GRP, while in general across the country it is 2.8%. Financing of the consolidated healthcare budget in 2007 amounted to 3932.5 roubles per head, which is lower than normative indicators in RF by 19.2 roubles (in RF 3951.7 roubles). In 2007, salaries healthcare amounted to 70% of average level of salary in the economy of the region.
Our research of financial aspects of the reform and its implementation on the level of municipal administrations of RT showed that, firstly, there is retained a system of latent underfinancing of municipal healthcare and underservice of medical care, and, secondly, certain kinds of medical care experience a syndrome of 'interchangeability of resources'. This is manifested by the fact that federal financing of certain medical services (for example, under the "birth certificate" program) allows regional and local governments to reallocate own funds to the financing of some other public benefit14.
Also, some attention should be given to the fact that the general volume of healthcare services provided under the "Program of state guarantees of provision of free medical care to citizens of RF" has not reduced. This seems to be one of the major problems of Russian healthcare system: relative insufficiency of state financing to cover spending on provision of free services. At the same time, in public opinion it is healthcare institutions and medical workers who are responsible for the insufficient
slaborazvitogo gosudarstva. URL: http://etnocid.netda.ru/analitika/akchurin.htm
14 See: Kulkova V.Yu., Mukharrjamova L.M., Shulaev A.V. (2008) Finansovye aspekty transformatsii otrasli na subregionalnom urovne v uslovijakh reformirovanija mestnogo samoupravlenija i realizatsii natsionalnogo proekta "Zdorovie". Natsionalnye interesy: prioritety I bezopasnost. 2008. m11. P.28-34.
provision of free, timely and high quality service.
If we add on to the above mentioned, we will state that during the same period an experiment on single-channeled financing has started, together with the processes of healthcare system optimization and introduction of a new system of the remuneration of labor, and it will become clear that the national project is executed in specific conditions, and both medical community and population have an ambiguous perception of the changes.
National project has received a wide coverage in mass media. As Eugenyi Gontmacher has noted "the results are presented by the press as the important achievements, but in reality they have quite an odd character and don't have principal impact on major problem solving in Russian healthcare"15. Our research of regional mass-media in Republic of Tatarstan (RT) and Republic of Mari El (RME) in 2006 has shown that the most discussed themes in this period were the purchase of medical equipment and medical transport (up to 30% of all statements), increase in salary of certain categories of medical workers (23.8%), making up of the staff of general practice and district doctors (20%), clinical examination of population (15%), "birth certificates" program (13.8%)16. The list of various directions of the national project primarily reflects the events, connected to the material resources. The mass-media statements "most often had the character of reports on amounts of obtained resources"17. Thus, national project has supported the formation of over
15 Gontmakher Ye.Sh. Ibid.
16	See: Mukharrjamova L.M., Kuznetzova-Morenko I.B., Kulkova V.Yu., Petrova R.G., Salakhatdinova L.N. Sotsialnaja politika v sfere zdravookhranenija v uslovijakh razgranitchenija bjudgetnykh polnomotchij v Respublike Tatarstan i Respublike Marij El // Socialnaya politica: realii XXI veka. Vipusk 3: GP3'2007. Independent Institute of Social Policy. Moscow: IISP. P. 267.
17	Kuznetzova-Morenko I.B. Reformy zdravookhranenija v SMI: opyt sociologicheskogo issledovanija // Socialnaja gizn regionov: mezhdu proshlym i buduschim. Formirovanie I
expectations of healthcare among population.
The estimation of state of health and self preservation behavior of population
Our research group conducted a mass poll concerning health estimation, self preservation behavior and satisfaction by medical aid in August -November, 2008. The sample of 829 respondents included inhabitants of Kazan, two big cities, also two average cities of Republic of Tatarstan18. Survey has been organized in hospitals, polyclinics, at the enterprises and organizations. Thus, we included the people who was on hospitalization (or in maternity hospital), passing inspection or treatment in polyclinics and those who at the moment of mass poll was not in direct contact to physicians ("population").
Questionnaires have been developed for each group of the respondents, containing identical basic questions and additional questions for separate categories. The questionnaire has been made with use of questionnaires and recommendations of experts State organization "Fund of obligatory medical insurance of Republic Tatarstan". Patients of hospitals received questionnaires in pure envelopes which surrendered in the sealed kind.
realizatzija socialnoj politiki v Rossijskoj Federatzii v uslovijah razgranichenija polnomochij mezhdu federalnym centrom, sub'ektami federatzii I organami mestnogo
samoupravlenija. Sbornik materialov. Moscow, 2007. P. 145.
18
Republic of Tatarstan is situated in the center of the Russian Federation on the East-European Plain. The overall territory of the Republic is 67,836.2 sq. km. The capital of the republic is Kazan. The Republic of Tatarstan is Russia's eighth largest region. According to the All-Russian Census of 2002 (from the State Statistical Committee of the Republic of Tatarstan) the population of the Republic of Tatarstan is 3,779,300 people. Tatarstan is one of the most economically developed subjects of the Russian Federation. Main resources include crude oil, land, and water resources.
The self-estimation of health of the population shows that approximately half characterize it as "average". "Very good" health can name no more than 5.1 %, and "good" - from 19.2 % (patients of hospitals) to 33.1 % (visitors of polyclinics). Estimate health as "bad" or "very bad" on the average the one tenth respondents (see Table 1).
Table 1: Self estimation of health by population, which was not in a hospital and polyclinics at the moment of survey (%)
Respondents	Population	Visitors of	Patient of
		polyclinics	hospitals
Self-estimation of health			
Very good	5	5,1	2,6
Good	33,1	24,3	19,2
Average	51,7	58	59,3
Bad	7	8,1	11
Very bad	0,3	2,2	3,1
I find it difficult to answer	2,6	1,5	3,1
The self-estimation of health caused by existence or absence problems with health. One tenth of respondents marked aggravation of chronic disease, and 8.6 % - serious disease (see Table 2)
Table 2: "Whether you had any problems with health for last 30 days?'
Problems with a health	%
Easy indisposition	47
Aggravation of chronic disease	10,8
Serious disease	8,6
No	31,5
There is more than half of respondents had chronic diseases. From among the population which were not staying at the moment of mass poll in medical institutions, the share of those makes 50 %, 55,9 %
among visitors of polyclinics and 60,6 % - patients of hospitals. The 15.6 % of respondents suffered from gastro enteric chronic diseases, 7.9 % -diseases of cardiovascular system, 7.9 % - diseases of urinogenital system, 7.3 % - diseases of respiratory bodies, 3.3 % - neurologic diseases, 1.7 % - mental illness. Research revealed the big share of the population self-medicating: so, among the population which were not staying in medical institutions or in polyclinics, 27 % were treated independently. From 5.4 to 7.6 % of respondents were not treated independently and did not address for medical aid during the illness (see Table 3).
Medical preventive maintenance finds just small number of supporters among the population. So, 12.2 % of respondents noticed that they "never passed prophylactic medical examination", and 17.2 % found it difficult to answer whether they passed prophylactic medical examination that also can mean negative answer. 33.1 % of female respondents addressed to the gynecologist less often, than once in half a year (the norm is one visiting once in six months).
There are different factors of lack of attitudes of passing medical prophylactic medical examination. The first factor is the luck of trust to medical institutions, the second is a question of free time. According date of our survey 35.6 % of respondents work more than nine hours a day daily. Obviously such a schedule doesn't help to give attention to medical prophylactic examination.
The cited data can testify the absence of understanding of necessity of maintenance of health as parts of daily practices and style of life. Absence of culture of maintenance of health has been revealed by Irina Nazarova on the basis of a number of the All-Russia and regional surveys: "The person gets to such \situation when health ceases to be a synonym
of life and is opposed to it"
19
Table 3: Whether did you address for medical health in case of disease or illness?
	Population	Visitors of polyclinics	Patients of hospitals
Yes	20,4	52,2	69,6
No, threaten by myself	27,4	27,2	12,8
No, did not address to medical institutions and did not treat by myself	7,6	5,1	5,4
Research of satisfaction in healthcare of population of Republic of Tatarstan
Research of population's satisfaction in healthcare in the region has become a normal practice. According to Minister for Healthcare of RT Airat Farrakhov, many chief medical officers conduct their own research in the levels of satisfaction among their patients. The system of surveys of mothers implemented by the Coordinator Service in the Child republican clinical hospital (CRCH) is presented as a positive example. Coordinators are the most experienced and competent medical nurses with higher education degree, personally subordinate to the chief medical officer. They do their inspections and interviewing in the evenings, when the impact of department heads and doctors in charge of the case is minimal. The results of the surveys are debriefed during the morning report together with the deputies to the chief medical officer, as well as during the work conferences, that is all defects are eliminated on-the-fly. In his interview given during this research, chief
19
Nazarova I. Zdotovie zanyztgo naseleniya (Health of employees). State university High School of Economy. Moscow: MAX Press, 2007. P. 414.
medical officer of the CRCH E.V. Karpukhin said that this kind of coordinator-conducted surveys is not capable of giving the objective evaluation of satisfaction rates: the impact of 'the walls' and of the medical worker's status is significant. However, in his opinion this form gives him as a chief officer a possibility to efficiently react upon most sharp and demanding situations, connected with organization of treatment and communication between patients and their parents with hospital staff.
According to the Minister, another way of exploring patients' opinion is the establishment of special portals in large republican healthcare institutions and conduction of the so-called "exit polls", i.e. interviews with the already discharged patients. In the course of the interview conducted within our research, Minister for healthcare of RT told about his personal monitoring of the evaluation of quality of healthcare services on specialized web-sites. For example, Kazan web-site www.mamakazan.ru publishes a rating of maternity hospitals of the city based on the comments made by the women recently confined. Mothers comment on their impressions, on collaboration with doctors and midwives, on "prearranged" delivery, express their gratitude to the doctors or warn about non-qualified or rude specialists. 20
Insurance companies conduct their own researches, together with organization of "open doors" days for patients, analysis of written complaints and claims.
Official documents of the Ministry for Healthcare of Republic of Tatarstan
20 Analysis of comments on this site allows for certain comclusions about birth certificates, implemented within the national project "Health". They have not influenced the practice of "personal pre-arrangements", and the advice to have a "pre-arranged delivery" can be heard practically in all comments, while birth certificates are not mentioned at all. However, this might be characteristic only of Internet-users.
show a high degree of population's satisfaction with medical care. First deputy to the Minister A. Yu. Vafin has reported on the Ministerial meeting in March 2008 on the results of the survey of patients on the questions of satisfaction with the quality of hospital services. In the course of survey, 436 patients were interviewed in 12 medical institutions. The results of the survey showed that 88% of interviewees have not experienced any difficulties with hospitalization, and only one patient in ten has faced queues. Also, survey showed high levels of satisfaction with the quality of examination - 89% and quality of treatment - 80% of interviewees, who have also marked professional qualities of doctors as competent specialists (86%). At the same time only 60% of patients view doctors as benevolent. Each third patient of the hospital (31.2%) had to purchase drugs for treatment received within the hospital out of personal resources, which had not affected the evaluation of the quality of treatment. Only one out of 436 interviewees disclosed the fact of giving money to the doctor. Integral satisfaction with the quality of treatment amounted to 80%21.
During the fall of the same year, I.I. Vasilieva, Head of Department of economic analysis of medical security resources of the Ministry for Healthcare of RT has announced that the level of satisfaction with the quality of medical help in institutions, working under the pilot project of quality assurance in healthcare amounted to 72%.
Medical help was evaluated in terms of "good quality" or "good quality in most cases" by 63.2% of interviewed patients, and 18% regard services provided by medical workers as of "poor quality" and "poor quality in most cases". The other interviewees had difficulties with answering this
21
Statement by A. Yu. Vafina made on a meeting of Ministry for Healthcare of RT "O realizatsii antikorruptsionnoj politiki v zdravookhranenii Respubliki Tatarstan". Available at: minzdrav.tatar.ru/rus/doklad.htm?page=28pub_id=17480
question. It turned out as a complete surprise for us that the distribution of satisfaction rates between different groups of patients was almost equal: 64.1% of patients, interviewed in hospitals and the same amount of interviewees from "general population" have evaluated medical care as of "good quality" and "good quality in most cases". The group that pronounces low quality of care is slightly bigger in "population" 22.1% vs. 14.4% in hospital patients. Why have these results become a surprise? We assumed that hospital patients will show quite understandable cautiousness in the environment of medical institutions and will award higher marks in their evaluations. One of the heads of municipal healthcare departments articulated this viewpoint in the course of the interview: "patients aren't self-murderers; they will not take risks during their hospital treatment period. Everyone thinks he might be tracked down." We supposed that people not currently under the medical treatment will contrarily give lower evaluations, guided not only by personal impressions, but also by judgments by their friends, relatives and mass-media. As is well known, the most discussed issues are violations and failures in treatment. However, both groups showed practically identical results. We are inclined to think that this positive effect was produced by the chosen organization method of the survey. Polyclinic patient show a lower, but generally comparable rate of satisfaction: there are 57.5% of those satisfied with medical help, and every fourth interviewee is dissatisfied.
What are possible interpretations of the results and what kind of questions is stirred by them? Firstly, satisfaction level in Tatarstan turned out to be higher than in the all-Russian poll conducted in the mid-2000 years. Should this fact be regarded as a result of general rise in living standards, improvements in healthcare system as a result of implementation of the first stage of national project, or particular optimism of Tatarstan people? These questions should be answered
within further research.
Secondly, there is a significant and clear difference in the share of those satisfied with medical care compared to the data of the Ministry for healthcare of RT (72-80%). According to the Agreement between Ministry for healthcare and social development of RF, Cabinet of Ministers of RT and Fond of Obligatory Medical Insurance on implementation of pilot project on quality assurance of healthcare services, the rate of satisfaction should amount to 82%, and acceptance of increased responsibilities under this agreement by the Ministry could lead to desire for "improved" of outcomes. It is clear, that "improved" of statistics does not lead to real improvement of state of affairs, but on the contrary, could hinder the opportunities to react to existing troubles.
Thirdly, despite the fact that national project was primarily oriented towards strengthening of primary healthcare it is precisely in polyclinics where there are more dissatisfied patients22. Among other problems of medical service interviewees most frequently identify issues concerned with policlinics' competence. 33.9% mention long queues to receive consultation from a district doctor, 25.6% - many days waiting period for consultations of a narrow specialist and every fourth (24.4%) complains about long queue or even impossibility to receive ultrasound check or electrocardiographic monitoring. Every sixth interviewee is dissatisfied with the fact that queues for submitting blood for tests run up to several days, and the same amount complain about impossibility to choose their district doctor for themselves.
22 Results of all researches show that the worst claims are directed on the work of polyclinics. See: Shilova L.S. O strategii povedenija ljudej v uslovijakh reformy zdravookhranenija // Sociologicheskii issledovanija. 2007. ^9. ^.102-109.
It seems that this state of affairs indicated some problems that have not received solution under the national project, and, moreover, aggravated. Let's turn to the facts. In 2006-2007 432 units of new medical equipment were placed in Tatarstan polyclinics. Naturally, new equipment required additional room. Also, 169 general practice departments and offices were established with the staff of 826 GP doctors. According to estimates of specialists, introduction of general practice required individual offices for doctors, nurses and rooms for manipulations with total area of 54sq.m. At the same time, given that in the last ten years priority development of ambulatory-polyclinic care (APC) was pronounced in the region, its real capacities have grown by only 3.5%. And even this growth occurred only due to urban areas, at the expense rural districts, where APC capacities have diminished by 11%23. Expanded need in new premises and facilities combined with sharp deficit of room in polyclinics. As a result, even under conditions of three-shift usage of every single office in the polyclinic, it is hard to avoid queues and overcrowding.
And eventually, there is one more circumstance that requires specific attention. In accordance with research analytic goals, the sampling of survey meets generally accepted standards of reliability of obtained results is in principle quite reliable. However, talks with interviewees, discussions of the results with practicing doctors have always prompted us to the conclusion that obtained satisfaction rate (63.2%) is overestimated. Results of qualitative research directly indicate low levels of satisfaction with the quality of medical care. Authors of qualitative research, conducted in Saint-Petersburg in 2004, received only 2 positive responses about Russian healthcare out of 29 interviews. Researchers state, that "a mechanistic and anti-humanitarian approach was constructed, where a person found him/herself helpless and passive
23 Gilmanov A.A. Problemy v organizatzii ambulatorno-poliklinicheskoj pomoschi naseleniju. Available at: minzdrav.tatar.ru/rus/doklad.htm?page=28pub_id=17481
24
object of manipulations"
Why do people, expressing numerous claims to healthcare and medical workers in the course of conversation, are reservedly benevolent in their answers in the survey? A questionnaire is a written document, that binds personal expressions, elevates the significance of the event. Those who answer the questions intentionally or unintentionally forecast possible outcomes of the analysis of their answers. And the whole of their life experience tells them that the ones to be charged will be appointed out of those, who perform their jobs of tremendous complexity and responsibility for very low remuneration. We conceive this in terms of population to a significant degree demonstrating social solidarity with medical workers, through positive evaluation of healthcare system on a whole. Having low level of knowledge about self preservation, population shifts responsibility of care about their bodies on medical workers, which creates a special attitude towards medical workers as to possessors of "secret knowledge" and power. Evaluation of these attitudes presents new tasks for future investigations.
References
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